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Kapoor M, Reddel SW. Ways to think about vasculitic neuropathy. Curr Opin Neurol 2024:00019052-990000000-00185. [PMID: 39046107 DOI: 10.1097/wco.0000000000001301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
PURPOSE OF REVIEW Vasculitis as a pathomechanism for neuropathy can be isolated to the peripheral nervous system, a part of a systemic autoimmune condition or a component of another syndrome. This review aims to discuss the broad range of diagnoses in which vasculitic neuropathy can be encountered, highlight the progress in imaging techniques in identifying vasculitis, and the new drugs developed for other autoimmune diseases that may be applied to neurological conditions. RECENT FINDINGS Advances in imaging modalities, ultrasound, MRI and FDG-PET scanning for neuromuscular applications has redefined many aspects of vasculitic neuropathies. The benefit of dividing vasculitides by vessel size is becoming less absolute as diagnostic approaches advance. MRI and FDG-PET are widely used in diagnosis, defining extent of involvement of disease and monitoring. In neuralgic amyotrophy, the identification of hourglass-like constrictions on imaging has changed the treatment paradigm to include surgical interventions. These diagnostic approaches are supported by new immunomodulating and immunosuppression techniques. SUMMARY Vasculitic neuropathies are a broad group of conditions with a range of causes and associations. Increased use of imaging techniques impacts our traditional definitions and classifications. The growth in treatment options for other autoimmune conditions are likely to infiltrate the neurological landscape.
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Affiliation(s)
- Mahima Kapoor
- Department of Neurosciences, Central Clinical School, Monash University, Alfred Centre, Melbourne, Victoria
| | - Stephen W Reddel
- ANZAC Research Institute, Central Clinical School, University of Sydney, Sydney, Australia
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2
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[Peripheral neuropathies during systemic diseases: Part II (vasculitis)]. Rev Med Interne 2023; 44:174-180. [PMID: 36925342 DOI: 10.1016/j.revmed.2023.01.003] [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: 11/07/2022] [Accepted: 01/08/2023] [Indexed: 03/15/2023]
Abstract
Primary systemic vasculitides, mainly of the small and medium-sized vessels, are frequently associated with peripheral neuropathies. When the disease is already known, the appearance of a neuropathy should suggest a specific injury, especially when associated with other systemic manifestations. Conversely, when neuropathy is inaugural, close collaboration between neurologists and internists is necessary to reach a diagnosis. A standardized electro-clinical investigation specifying the topography, the evolution and the mechanism of the nerve damage enables the positive diagnosis of the neuropathy. Several elements orient the etiological diagnosis and allow to eliminate the main differential diagnosis: non systemic vasculitic neuropathy. The existence of associated systemic manifestations (glomerular or vascular nephropathy, interstitial lung disease, intra-alveolar hemorrhage, ENT involvement…), biological markers (ANCA, cryoglobulinemia, rheumatoid factor), and invasive examinations allowing histological analysis (neuromuscular biopsy) are all useful tools for.
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Mansueto G, Lanza G, Falleti J, Orabona P, Alaouieh D, Hong E, Girolami S, Montella M, Fisicaro F, Galdieri A, Singh P, Di Napoli M. Central and Peripheral Nervous System Complications of Vasculitis Syndromes from Pathology to Bedside: Part 2-Peripheral Nervous System. Curr Neurol Neurosci Rep 2023; 23:83-107. [PMID: 36820992 PMCID: PMC9947450 DOI: 10.1007/s11910-023-01249-3] [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: 01/18/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Peripheral nervous system vasculitides (PNSV) are a heterogeneous group of disorders with a clinical subset that may differ in prognosis and therapy. We provide a comprehensive update on the clinical assessment, diagnosis, complications, treatment, and follow-up of PNSV. RECENT FINDINGS Progress in neuroimaging, molecular testing, and peripheral nerve biopsy has improved clinical assessment and decision-making of PNSV, also providing novel insights on how to prevent misdiagnosis and increase diagnostic certainty. Advances in imaging techniques, allowing to clearly display the vessel walls, have also enhanced the possibility to differentiate inflammatory from non-inflammatory vascular lesions, while recent histopathology data have identified the main morphological criteria for more accurate diagnosis and differential diagnoses. Overall, the identification of peculiar morphological findings tends to improve diagnostic accuracy by defining a clearer boundary between systemic and non-systemic neuropathies. Therefore, the definition of epineurium vessel wall damage, type of vascular lesion, characterization of lymphocyte populations, antibodies, and inflammatory factors, as well as the identification of direct nerve damage or degeneration, are the common goals for pathologists and clinicians, who will both benefit for data integration and findings translation. Nevertheless, to date, treatment is still largely empiric and, in some cases, unsatisfactory, thus often precluding precise prognostic prediction. In this context, new diagnostic techniques and multidisciplinary management will be essential in the proper diagnosis and prompt management of PNSV, as highlighted in the present review. Thirty to fifty percent of all patients with vasculitis have signs of polyneuropathy. Neuropathies associated with systemic vasculitis are best managed according to the guidelines of the underlying disease because appropriate workup and initiation of treatment can reduce morbidity. Steroids, or in severe or progressive cases, cyclophosphamide pulse therapy is the standard therapy in non-systemic vasculitic neuropathies. Some patients need long-term immunosuppression. The use of novel technologies for high-throughput genotyping will permit to determine the genetic influence of related phenotypes in patients with PNSV.
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Affiliation(s)
- Gelsomina Mansueto
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Piazza L. Miraglia 2, 80138, Naples, Italy.,Clinical Department of Laboratory Services and Public Health-Legal Medicine Unit, University of Campania "Luigi Vanvitelli", Via Luciano Armanni 5, 80138, Naples, Italy.,Pathology-Unit of Federico II University, Via S. Pansini 3, 80131, Naples, Italy
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy.,Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Via Conte Ruggero 73, 94018, Troina, Italy
| | - Jessica Falleti
- Pathology Unit, Sant'Anna E San Sebastiano Hospital, 81100, Caserta, Italy
| | - Pasquale Orabona
- Pathology Unit, Sant'Anna E San Sebastiano Hospital, 81100, Caserta, Italy
| | | | - Emily Hong
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Sara Girolami
- Neurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039, Sulmona, L'Aquila, Italy
| | - Marco Montella
- Mental and Physical Health and Preventive Medicine Department, University of Campania "Luigi Vanvitelli", Via Luciano Armanni 5, 80138, Naples, Italy
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123, Catania, Italy
| | - Anna Galdieri
- AOU "Luigi Vanvitelli", Via Santa Maria Di Costantinopoli 104, 80138, Naples, Italy
| | - Puneetpal Singh
- Department of Human Genetics, Punjabi University, Patiala, 147002, Punjab, India
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039, Sulmona, L'Aquila, Italy.
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Soulages A, Maisonobe T, Auzou P, Petit A, Allenbach Y, Barète S, Skopinski S, Ribeiro E, Jullié ML, Lamant L, Brevet F, Soulages X, Vallat JM, Martin-Négrier ML, Solé G, Duval F, Carla L, Le Masson G, Mathis S. Peripheral neuropathy and livedoid vasculopathy. J Neurol 2022; 269:3779-3788. [PMID: 35166926 DOI: 10.1007/s00415-022-11007-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/24/2021] [Accepted: 02/02/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Livedoid vasculopathy (LV) is a chronic dermatosis associated with micro-thrombosis of the vessels of the dermis, leading to ischemic lesions and painful skin ulcerations of the lower limbs. This thrombosing occlusive vasculopathy, clearly distinct from 'classical vasculitis' (not related to alteration of vessel walls), may lead to peripheral neuropathy. OBJECTIVE To clarify the main clinical, electrophysiological and pathological characteristics of peripheral neuropathy linked to LV. METHOD We presented a series of personal cases of peripheral neuropathy due to LV. We also conducted a review of the literature (since the first description of LV in 1974) using multiple combinations of keywords from 'PubMed', 'Google Scholar' and 'ScienceDirect' databases according to the 'Preferred Reporting Items for Systematic reviews and Meta-Analyses' guidelines. RESULTS We identified 16 patients (6 personal cases and 10 cases from the medical literature). Our personal cases were five females and one male, with a median age (at the onset of cutaneous signs of LV) of 38 (range 25-62). Several types of skin lesions of the lower limbs were observed. Median age at the onset of peripheral neuropathy symptoms was 48 years (range 29-66), with a main clinical and electrophysiological pattern of mononeuropathy multiplex. DISCUSSION We observed a typical pattern of peripheral neuropathy, mostly mononeuropathy multiplex, whose pathophysiology might be related to occlusions of the small vessels of the nerves, as seen in the dermis. Moreover, LV may also be associated with other types of peripheral neuropathies (sometimes of autoimmune etiology) not directly related to the skin lesions. CONCLUSION The 'ischemic form' of peripheral neuropathy linked to LV is mainly responsible for sensory disturbances (with multifocal distribution), sometimes for motor disturbances. This type of peripheral neuropathy has to be distinguished from 'classical vasculitic neuropathies' which are usually treated with antithrombotic therapies.
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Affiliation(s)
- Antoine Soulages
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Thierry Maisonobe
- Department of Clinical Neurophysiology, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Pascal Auzou
- Department of Neurology, CHR Orléans, Orléans, France
| | - Antoine Petit
- Department of Dermatology, AP-HP, Saint-Louis Hospital, Paris, France
| | - Yves Allenbach
- Department of Internal Medicine and Clinical Immunology, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Stéphane Barète
- Department of Dermatology, Sorbonne Université (UPMC Paris-6), Paris, France
| | - Sophie Skopinski
- Department of Vascular Medicine, University Hospital of Bordeaux (CHU Bordeaux, Saint-André Hospital), Bordeaux, France
| | - Emmanuel Ribeiro
- Department of Internal Medicine and Tropical Diseases, University Hospital of Bordeaux (CHU Bordeaux, Saint-André Hospital), Bordeaux, France
| | - Marie-Laure Jullié
- Department of Pathology, University Hospital of Bordeaux (CHU Bordeaux, Haut-Lévêque Hospital), Pessac, France
| | - Laurence Lamant
- Department of Pathology, Institut Universitaire du Cancer de Toulouse, Oncopole (IUC-T), Toulouse, France
| | | | - Xavier Soulages
- Neurology Office, 23 Boulevard de la République, Rodez, France
| | - Jean-Michel Vallat
- Department of Neurology, University Hospital of Limoges (Dupuytren Hospital), Limoges, France
| | - Marie-Laure Martin-Négrier
- Department of Pathology, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Guilhem Solé
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Fanny Duval
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Louis Carla
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Gwendal Le Masson
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France
| | - Stéphane Mathis
- Department of Neurology, Nerve-Muscle Unit, Referral Center for Neuromuscular Diseases AOC, University Hospital of Bordeaux (CHU Bordeaux, Pellegrin Hospital), Bordeaux, France.
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Soulages A, Sibon I, Vallat JM, Ellie E, Bourdain F, Duval F, Carla L, Martin-Négrier ML, Solé G, Laurent C, Monnier A, Le Masson G, Mathis S. Neurologic manifestations of giant cell arteritis. J Neurol 2022; 269:3430-3442. [DOI: 10.1007/s00415-022-10991-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 10/19/2022]
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6
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El-Abassi RN, Soliman M, Levy MH, England JD. Treatment and Management of Autoimmune Neuropathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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7
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Tulbă D, Popescu BO, Manole E, Băicuș C. Immune Axonal Neuropathies Associated With Systemic Autoimmune Rheumatic Diseases. Front Pharmacol 2021; 12:610585. [PMID: 33935704 PMCID: PMC8079948 DOI: 10.3389/fphar.2021.610585] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 03/10/2021] [Indexed: 01/19/2023] Open
Abstract
Immune axonal neuropathies are a particular group of immune-mediated neuropathies that occasionally accompany systemic autoimmune rheumatic diseases such as connective tissue dissorders and primary systemic vasculitides. Apart from vasculitis of vasa nervorum, various other mechanisms are involved in their pathogenesis, with possible therapeutic implications. Immune axonal neuropathies have highly heterogeneous clinical presentation and course, ranging from mild chronic distal sensorimotor polyneuropathy to severe subacute mononeuritis multiplex with rapid progression and constitutional symptoms such as fever, malaise, weight loss and night sweats, underpinning a vasculitic process. Sensory neuronopathy (ganglionopathy), small fiber neuropathy (sensory and/or autonomic), axonal variants of Guillain-Barré syndrome and cranial neuropathies have also been reported. In contrast to demyelinating neuropathies, immune axonal neuropathies show absent or reduced nerve amplitudes with normal latencies and conduction velocities on nerve conduction studies. Diagnosis and initiation of treatment are often delayed, leading to accumulating disability. Considering the lack of validated diagnostic criteria and evidence-based treatment protocols for immune axonal neuropathies, this review offers a comprehensive perspective on etiopathogenesis, clinical and paraclinical findings as well as therapy guidance for assisting the clinician in approaching these patients. High quality clinical research is required in order to provide indications and follow up rules for treatment in immune axonal neuropathies related to systemic autoimmune rheumatic diseases.
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Affiliation(s)
- Delia Tulbă
- Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania.,Colentina-Research and Development Center, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan Ovidiu Popescu
- Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Laboratory of Cell Biology, Neurosciences and Experimental Myology, "Victor Babeș" National Institute of Pathology, Bucharest, Romania
| | - Emilia Manole
- Laboratory of Cell Biology, Neurosciences and Experimental Myology, "Victor Babeș" National Institute of Pathology, Bucharest, Romania
| | - Cristian Băicuș
- Colentina-Research and Development Center, Colentina Clinical Hospital, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Internal Medicine, Colentina Clinical Hospital, Bucharest, Romania
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8
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Berti A, Bond M, Volpe A, Felicetti M, Bortolotti R, Paolazzi G. Practical approach to vasculitides in adults: an overview of clinical conditions that can mimic vasculitides closely. ACTA ACUST UNITED AC 2020. [DOI: 10.4081/br.2020.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Primary systemic vasculitides are rare diseases affecting blood vessel walls. The type and patterns of distribution of the organs affected usually reflect the size of the vessels predominantly involved, and the patterns of clinical manifestations are generally useful to reach a specific diagnosis. However, presenting symptoms may lack adequate specificity for a prompt diagnosis, leading to a diagnostic (and therapeutic) delay, often causing irreversible damage to the affected organs. Due to their rarity and variable clinical presentation, the diagnosis of primary vasculitides could be challenging for physicians. Vasculitis mimickers, i.e. the clinical conditions that could be likely mistaken for vasculitides, need to be carefully ruled out, especially before starting the immunosuppressive therapy. We present here a practical approach to the diagnosis of primary systemic vasculitides involving large, medium and small size vessels, and reviewed most of the conditions that could mimic primary systemic vasculitides.
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9
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[Polyneuropathies in vasculitis and connective tissue diseases : Clinical manifestations and diagnostic recommendations]. Internist (Berl) 2020; 61:261-269. [PMID: 32072188 DOI: 10.1007/s00108-020-00755-7] [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: 10/25/2022]
Abstract
Vasculitic neuropathies result from inflammation of the vasa nervorum followed by ischemia and destruction of the peripheral nerve. The inflammation can be systemic or localized, i.e. non-systemic. Systemic vasculitis can be divided into primary and secondary forms. The latter is associated with, e.g. connective tissue diseases, infections, cancer or induced by certain drugs. Around two thirds of patients with systemic vasculitis develop vasculitic neuropathy presenting as characteristic painful, multifocal mononeuropathy of acute onset. The group of non-systemic neuropathies has grown in recent years with the addition of diabetic and non-diabetic lumbosacral radiculoplexus neuropathies, among others. Within the group of connective tissue diseases, other non-vasculitic neuropathies can occur as nerve-entrapment syndromes and sensory ataxic neuropathy. The aim of this article is to present a condensed overview of neuropathies associated with vasculitis and connective tissue diseases and to communicate characteristic clinical symptoms supporting rapid diagnostic and therapeutic procedures.
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10
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Kate M, Deolalikar S, M. Paul P, Jaison V, Nandi J, Arora D, Pandian J. Clinical, electrophysiological, and histopathological profile of biopsy-proven vasculitic neuropathy. CHRISMED JOURNAL OF HEALTH AND RESEARCH 2020. [DOI: 10.4103/cjhr.cjhr_34_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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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.
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Affiliation(s)
- I Y Golovach
- Feofaniya Clinical hospital State Management of Affairs
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12
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Abstract
PURPOSE OF THE REVIEW Cryoglobulins are immunoglobulins with the ability to precipitate at temperatures <37 °C. They are related to hematological disorders, infections [especially hepatitis C virus (HCV)], and autoimmune diseases. In this article, the state of the art on Cryoglobulinemic Vasculitis (CV), in a helpful and schematic way, with a special focus on HCV related Mixed Cryoglobulinemia treatment are reviewed. RECENT FINDINGS Direct - acting antivirals (DAA) against HCV have emerged as an important key in HCV treatment to related Cryoglobulinemic Vasculitis, and should be kept in mind as the initial treatment in non-severe manifestations. On the other hand, a recent consensus panel has published their recommendations for treatment in severe and life threatening manifestations of Mixed Cryoglobulinemias. HCV-Cryoglobulinemic vasculitis is the most frequent form of CV. There are new treatment options in HCV-CV with DAA, with an important number of patients achieving complete response and sustained virologic response (SVR). In cases of severe forms of CV, treatment with Rituximab and PLEX are options. The lack of data on maintenance therapy could impulse future studies in this setting.
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Affiliation(s)
- Alejandro Fuentes
- Departamento de Inmunología clínica y Reumatología, Pontificia Universidad Católica de Chile, Diagonal Paraguay, #362, Santiago, Chile
| | - Claudia Mardones
- Departamento de Inmunología clínica y Reumatología, Pontificia Universidad Católica de Chile, Diagonal Paraguay, #362, Santiago, Chile
| | - Paula I Burgos
- Departamento de Inmunología clínica y Reumatología, Pontificia Universidad Católica de Chile, Diagonal Paraguay, #362, Santiago, Chile.
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Recommendations for managing the manifestations of severe and life-threatening mixed cryoglobulinemia syndrome. Autoimmun Rev 2019; 18:778-785. [PMID: 31181326 DOI: 10.1016/j.autrev.2019.06.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/22/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Some of the manifestations of mixed cryoglobulinemia syndrome (MCS) can be severe or life-threatening, and should be rapidly contained but, as the therapeutic approaches to such conditions are largely based on anecdotal data, a consensus conference was organised by the Italian Group for the Study of Cryoglobulinemia (GISC) with the aim of providing a set of recommendations based on an in-depth survey of the available data and expert opinion. METHODS The consensus panel, which included specialists working in different medical fields involved in the management of MCS patients, was first asked to divide the manifestations of MCS into severe or life-threatening conditions on the basis of their own experience, after which a complete literature review was carried out in accordance with the Cochrane guidelines for systematic reviews. RESULTS Therapeutic plasma exchange (TPE) was considered the elective first-line treatment in the case of life-threatening manifestations of MCS (LT-MCS) and patients with severe clinical symptoms (S-MCS) who fail to respond to (or who are ineligible for) other treatments. The data supporting the combined use of cyclophosphamide and TPE were considered limited and inconclusive. High-dose pulsed glucocorticoid (GCS) therapy can be considered the first-line treatment of severe MCS, generally in association with TPE. Rituximab (RTX)-based treatments should be considered in patients with skin ulcers, peripheral neuropathy or glomerulonephritis, and in patients with persistent LT-MCS after TPE. In patients with hepatitis C virus-related MCS with S-MCS, viral eradication should be attempted as soon as a patient's condition allows the use of direct-acting antivirals.
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15
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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.
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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
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Yamasaki G, Okano M, Nakayama K, Jimbo N, Sendo S, Tamada N, Misaki K, Shinkura Y, Yanaka K, Tanaka H, Akashi K, Morinobu A, Yokozaki H, Emoto N, Hirata KI. Acute Pulmonary Hypertension Crisis after Adalimumab Reduction in Rheumatoid Vasculitis. Intern Med 2019; 58:593-601. [PMID: 30773522 PMCID: PMC6421146 DOI: 10.2169/internalmedicine.1143-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Rheumatoid vasculitis is a rare etiology for pulmonary hypertension (PH) in patients with connective tissue disease. We encountered a case of acute PH crisis in a case with rheumatoid vasculitis eight months after undergoing adalimumab reduction. Since no repetition of arthralgia occurred after the adalimumab reduction, we decided to not increase the dose of adalimumab. However, hemodynamic collapse thereafter developed and even though steroid pulse therapy was administered, the patient nevertheless died. The autopsy showed clusters of acute and chronic inflammation around the remodeled pulmonary arteries along with micro-thrombi in the vessel lumen. We should consider the possibility of critical worsening of PH as a phenotype of vasculitis related to immunosuppressive therapy reduction.
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Affiliation(s)
- Gentaro Yamasaki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Mitsumasa Okano
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kazuhiko Nakayama
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Naoe Jimbo
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Japan
| | - Sho Sendo
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Naoki Tamada
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenta Misaki
- Department of Rheumatology, Kita-Harima Medical Center, Japan
| | - Yuto Shinkura
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kenichi Yanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Kengo Akashi
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Akio Morinobu
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hiroshi Yokozaki
- Division of Pathology, Department of Pathology, Kobe University Graduate School of Medicine, Japan
| | - Noriaki Emoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
- Department of Clinical Pharmacy, Kobe Pharmaceutical University, Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
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Kawagashira Y, Koike H, Kawabata K, Takahashi M, Ohyama K, Hashimoto R, Iijima M, Katsuno M, Sobue G. Vasculitic Neuropathy Following Exposure to a Glyphosate-based Herbicide. Intern Med 2017; 56:1431-1434. [PMID: 28566611 PMCID: PMC5498212 DOI: 10.2169/internalmedicine.56.8064] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 01/05/2017] [Indexed: 01/12/2023] Open
Abstract
We herein report a case of peripheral neuropathy following exposure to large amounts of glyphosate-based herbicide. A 70-year-old man suffered from pain and purpura in the left sole following exposure to glyphosate-based herbicide. Pain and purpura spread to the opposite side and increased in severity. Mild weakness of the lower limbs was also observed. A sural nerve biopsy revealed the infiltration of lymphocytes around small vessels in the epineurium with numerous eosinophils, deposition of hemosiderins and focal axonal degeneration, compatible with findings of vasculitic neuropathy. Glyphosate-based herbicides should be recognized as a causative agent of vasculitic neuropathy.
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Affiliation(s)
- Yuichi Kawagashira
- Department of Neurology, Nagoya University Graduate School of Medicine, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Japan
| | - Kazuya Kawabata
- Department of Neurology, Nagoya University Graduate School of Medicine, Japan
| | - Mie Takahashi
- Department of Neurology, Nagoya University Graduate School of Medicine, Japan
| | - Ken Ohyama
- Department of Neurology, Nagoya University Graduate School of Medicine, Japan
| | - Rina Hashimoto
- Department of Neurology, Nagoya University Graduate School of Medicine, Japan
| | - Masahiro Iijima
- Department of Neurology, Nagoya University Graduate School of Medicine, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Japan
| | - Gen Sobue
- Nagoya University Graduate School of Medicine, Japan
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Illes Z, Blaabjerg M. Cerebrospinal fluid findings in Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2017; 146:125-138. [PMID: 29110767 DOI: 10.1016/b978-0-12-804279-3.00009-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The classic immunologic alteration of the cerebrospinal fluid (CSF) in Guillain-Barré syndrome (GBS), albuminocytologic dissociation, has been known since the original paper by Guillain, Barré, and Strohl. Albuminocytologic dissociation has been also described in other forms of the GBS spectrum, such as axonal motor or motor-sensory forms (AMAN, AMSAN), the anti-GQ1b spectrum of Miller Fisher syndrome, and Bickerstaff brainstem encephalitis. Cytokines, chemokines, antibodies, complement components, and molecules with a putative neuroprotective role or indicating axonal damage have also been examined using different methods. Besides these candidate approaches, proteomics has been recently applied to discover potential biomarkers. The overall results support the immunopathogenesis of GBS, but albuminocytologic dissociation remained the only consistent CSF biomarker supporting the diagnosis of GBS. Chronic inflammatory neuropathies also comprise a heterogeneous group of diseases. Increased protein in the CSF is a supportive factor of chronic inflammatory demyelinating polyneuropathy, especially in the absence of definite electrophysiologic criteria. A number of other markers have also been investigated in the CSF of patients with chronic inflammatory neuropathies, similar to GBS. However, none has been used in supporting diagnosis, differentiating among syndromes, or predicting the clinical course and treatment responses.
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Affiliation(s)
- Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Morten Blaabjerg
- Department of Neurology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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20
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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.
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21
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Callaghan BC, Price RS, Chen KS, Feldman EL. The Importance of Rare Subtypes in Diagnosis and Treatment of Peripheral Neuropathy: A Review. JAMA Neurol 2016; 72:1510-8. [PMID: 26437251 DOI: 10.1001/jamaneurol.2015.2347] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Peripheral neuropathy is a prevalent condition that usually warrants a thorough history and examination but has limited diagnostic evaluation. However, rare localizations of peripheral neuropathy often require more extensive diagnostic testing and different treatments. OBJECTIVE To describe rare localizations of peripheral neuropathy, including the appropriate diagnostic evaluation and available treatments. EVIDENCE REVIEW References were identified from PubMed searches conducted on May 29, 2015, with an emphasis on systematic reviews and randomized clinical trials. Articles were also identified through the use of the authors' own files. Search terms included common rare neuropathy localizations and their causes, as well as epidemiology, pathophysiology, diagnosis, and treatment. FINDINGS Diffuse, nonlength-dependent neuropathies, multiple mononeuropathies, polyradiculopathies, plexopathies, and radiculoplexus neuropathies are rare peripheral neuropathy localizations that often require extensive diagnostic testing. Atypical neuropathy features, such as acute/subacute onset, asymmetry, and/or motor predominant signs, are frequently present. The most common diffuse, nonlength-dependent neuropathies are Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and amyotrophic lateral sclerosis. Effective disease-modifying therapies exist for many diffuse, nonlength-dependent neuropathies including Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and some paraprotein-associated demyelinating neuropathies. Vasculitic neuropathy (multiple mononeuropathy) also has efficacious treatment options, but definitive evidence of a treatment effect for IgM anti-MAG neuropathy and diabetic amyotrophy (radiculoplexus neuropathy) is lacking. CONCLUSIONS AND RELEVANCE Recognition of rare localizations of peripheral neuropathy is essential given the implications for diagnostic testing and treatment. Electrodiagnostic studies are an important early step in the diagnostic evaluation and provide information on the localization and pathophysiology of nerve injury.
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Affiliation(s)
| | - Raymond S Price
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Kevin S Chen
- Department of Neurosurgery, University of Michigan, Ann Arbor
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor
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22
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Üçeyler N, Schäfer KA, Mackenrodt D, Sommer C, Müllges W. High-Resolution Ultrasonography of the Superficial Peroneal Motor and Sural Sensory Nerves May Be a Non-invasive Approach to the Diagnosis of Vasculitic Neuropathy. Front Neurol 2016; 7:48. [PMID: 27064457 PMCID: PMC4812111 DOI: 10.3389/fneur.2016.00048] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 03/15/2016] [Indexed: 12/16/2022] Open
Abstract
High-resolution ultrasonography (HRUS) is an emerging new tool in the investigation of peripheral nerves. We set out to assess the utility of HRUS performed at lower extremity nerves in peripheral neuropathies. Nerves of 26 patients with polyneuropathies of different etiologies and 26 controls were investigated using HRUS. Patients underwent clinical, laboratory, electrophysiological assessment, and a diagnostic sural nerve biopsy as part of the routine work-up. HRUS was performed at the sural, tibial, and the common, superficial, and deep peroneal nerves. The superficial peroneal nerve longitudinal diameter (LD) distinguished best between the groups: patients with immune-mediated neuropathies (n = 13, including six with histology-proven vasculitic neuropathy) had larger LD compared to patients with non-immune-mediated neuropathies (p < 0.05) and to controls (p < 0.001). Among all subgroups, patients with vasculitic neuropathy showed the largest superficial peroneal nerve LD (p < 0.001) and had a larger sural nerve cross-sectional area when compared with disease controls (p < 0.001). Enlargement of the superficial peroneal and sural nerves as detected by HRUS may be a useful additional finding in the differential diagnosis of vasculitic and other immune-mediated neuropathies.
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Affiliation(s)
- Nurcan Üçeyler
- Department of Neurology, University of Würzburg , Würzburg , Germany
| | | | - Daniel Mackenrodt
- Department of Neurology, University of Würzburg , Würzburg , Germany
| | - Claudia Sommer
- Department of Neurology, University of Würzburg , Würzburg , Germany
| | - Wolfgang Müllges
- Department of Neurology, University of Würzburg , Würzburg , Germany
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23
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High resolution neurography of the brachial plexus by 3Tesla magnetic resonance imaging. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.rxeng.2016.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Cejas C, Rollán C, Michelin G, Nogués M. High resolution neurography of the brachial plexus by 3 Tesla magnetic resonance imaging. RADIOLOGIA 2016; 58:88-100. [PMID: 26860655 DOI: 10.1016/j.rx.2015.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 09/23/2015] [Accepted: 12/16/2015] [Indexed: 12/23/2022]
Abstract
The study of the structures that make up the brachial plexus has benefited particularly from the high resolution images provided by 3T magnetic resonance scanners. The brachial plexus can have mononeuropathies or polyneuropathies. The mononeuropathies include traumatic injuries and trapping, such as occurs in thoracic outlet syndrome due to cervical ribs, prominent transverse apophyses, or tumors. The polyneuropathies include inflammatory processes, in particular chronic inflammatory demyelinating polyneuropathy, Parsonage-Turner syndrome, granulomatous diseases, and radiation neuropathy. Vascular processes affecting the brachial plexus include diabetic polyneuropathy and the vasculitides. This article reviews the anatomy of the brachial plexus and describes the technique for magnetic resonance neurography and the most common pathologic conditions that can affect the brachial plexus.
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Affiliation(s)
- C Cejas
- Departamento de Imágenes, Fundación para la lucha de las enfermedades neurológicas de la infancia Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina.
| | - C Rollán
- Departamento de Imágenes, Fundación para la lucha de las enfermedades neurológicas de la infancia Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina
| | - G Michelin
- Departamento de Imágenes, Fundación para la lucha de las enfermedades neurológicas de la infancia Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina
| | - M Nogués
- Departamento de Neurología, Fundación para la lucha de las enfermedades neurológicas de la infancia Dr. Raúl Carrea (FLENI), Buenos Aires, Argentina
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25
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Kamiya M, Shane PY, Soejima M, Tohda S, Miyasaka N, Kohsaka H. IgG4-Related Sialoadenitis with a Skin Lesion and Multiple Mononeuropathies Suggesting Coexistent Cryoglobulinemic Vasculitis. Intern Med 2016; 55:1355-61. [PMID: 27181547 DOI: 10.2169/internalmedicine.55.5332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 68-year-old man was admitted because of weakness of the left leg, dysesthesiae of the extremities and bilateral lower extremity purpura. A neurological examination showed mononeuritis multiplex with laboratory evidence of hypocomplementemia, cryoglobulinemia and leukocytoclastic vasculitis in the biopsy of a skin specimen. The patient also exhibited bilateral submandibular gland swelling, elevated serum IgG4 levels and infiltration of a large number of IgG4-positive plasma cells in the submandibular glands. These findings were consistent with both cryoglobulinemic vasculitis and IgG4-related disease. The administration of oral prednisolone (1 mg/kg/day) resolved the neurological manifestations and the swelling of the submandibular glands and cryoglobulinemia.
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Affiliation(s)
- Mari Kamiya
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Japan
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26
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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.
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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
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27
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Neuropatie delle vasculiti. Neurologia 2015. [DOI: 10.1016/s1634-7072(15)73992-9] [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
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28
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Üçeyler N, Geng A, Reiners K, Toyka KV, Sommer C. Non-systemic vasculitic neuropathy: single-center follow-up of 60 patients. J Neurol 2015; 262:2092-100. [DOI: 10.1007/s00415-015-7813-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/03/2015] [Accepted: 06/04/2015] [Indexed: 10/23/2022]
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29
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Blaes F. Diagnosis and therapeutic options for peripheral vasculitic neuropathy. Ther Adv Musculoskelet Dis 2015; 7:45-55. [PMID: 25829955 PMCID: PMC4357592 DOI: 10.1177/1759720x14566617] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Vasculitis can affect the peripheral nervous system alone (nonsystemic vasculitic neuropathy) or can be a part of primary or secondary systemic vasculitis. In cases of pre-existing systemic vasculitis, the diagnosis can easily be made, whereas suspected vasculitic neuropathy as initial or only manifestation of vasculitis requires careful clinical, neurophysiological, laboratory and histopathological workout. The typical clinical syndrome is mononeuropathia multiplex or asymmetric neuropathy, but distal-symmetric neuropathy can frequently be seen. Standard treatments include steroids, azathioprine, methotrexate and cyclophosphamide. More recently the B-cell antibody rituximab and intravenous immunoglobulins have shown to be effective in some vasculitic neuropathy types.
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Affiliation(s)
- Franz Blaes
- Department of Neurology, KKH Gummersbach, Wilhelm-Breckow-Allee 20, 51643 Gummersbach, Germany
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30
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Fanouriakis A, Kougkas N, Vassilopoulos D, Fragouli E, Repa A, Sidiropoulos P. Rituximab for eosinophilic granulomatosis with polyangiitis with severe vasculitic neuropathy: Case report and review of current clinical evidence. Semin Arthritis Rheum 2015; 45:60-6. [PMID: 25908179 DOI: 10.1016/j.semarthrit.2015.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 03/09/2015] [Accepted: 03/17/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Rituximab is approved for the treatment of granulomatosis with polyangiitis and microscopic polyangiitis. Our objective was to review published clinical evidence on the efficacy of rituximab in the treatment of eosinophilic granulomatosis and polyangiitis (EGPA). METHODS We describe a case of refractory EGPA with severe vasculitic neuropathy, which responded impressively to B-cell-depleting therapy. A systematic search of the English literature was also performed to capture all available clinical evidence on the use of rituximab in EGPA. RESULTS We identified a total of 73 EGPA patients who have been treated with rituximab, all data coming from case series or isolated case reports. The majority of patients (85.1%) were treated for refractory or relapsing disease; a mean (SD) of 2.1 (0.9) different immunosuppressive agents were used prior to rituximab administration. Efficacy of RTX therapy was significant in the majority of cases and in a wide variety of disease manifestations; however, a lack of standardized assessment of disease activity before and after treatment was observed in many reports. Overall, 54.0% of patients were treated with a single cycle of rituximab and only 10.8% experienced relapses of the disease. Few significant side effects were observed during a highly variable period of follow-up (3 months to 5 years), mainly severe infections and allergic reactions. CONCLUSIONS RTX seems to be effective in cases of severe EGPA refractory to standard of care immunosuppressive treatment, although support comes from case reports and non-controlled studies.
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Affiliation(s)
- Antonis Fanouriakis
- Department of Rheumatology, Clinical Immunology, and Allergy, University Hospital of Heraklion, Stavrakia Voutes, 71110, Heraklion, Crete, Greece.
| | - Nikolaos Kougkas
- Department of Rheumatology, Clinical Immunology, and Allergy, University Hospital of Heraklion, Stavrakia Voutes, 71110, Heraklion, Crete, Greece
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine, Hippokration General Hospital, Athens University School of Medicine, Athens, Greece
| | - Eleni Fragouli
- Department of Rheumatology, Clinical Immunology, and Allergy, University Hospital of Heraklion, Stavrakia Voutes, 71110, Heraklion, Crete, Greece
| | - Argyro Repa
- Department of Rheumatology, Clinical Immunology, and Allergy, University Hospital of Heraklion, Stavrakia Voutes, 71110, Heraklion, Crete, Greece
| | - Prodromos Sidiropoulos
- Department of Rheumatology, Clinical Immunology, and Allergy, University Hospital of Heraklion, Stavrakia Voutes, 71110, Heraklion, Crete, Greece
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31
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Painful multiple mononeuropathy as a first symptom of cardiac myxoma: an unusual clinical presentation. Cardiovasc Pathol 2014; 24:121-3. [PMID: 25283127 DOI: 10.1016/j.carpath.2014.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/29/2014] [Accepted: 09/10/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Atrial myxoma (AM) is responsible for multiple serious complications, such as ischemic stroke, and requires cardiac surgery. However, diagnosis and, thus, treatment may be delayed by an initial misleading clinical presentation including nonspecific extracardiac symptoms. Involvement of the peripheral nervous system as a first symptom of AM has been reported only once before and never in the form of multiple mononeuropathy. CASE We report the case of a 51-year-old woman who had suffered from pharmacoresistant neurological pain sequentially in several peripheral nerve territories for more than a year before the appearance of purpuric macules on the palms and soles and emergence of a biological inflammatory syndrome. Cardioembolic disease was suspected after radiological examination detected multiple asymptomatic renal and splenic infarctions and a small right frontal cortical ischemic stroke. Transoesophageal echocardiography revealed an atrial mass which was removed by surgery. AM was confirmed after histopathological analysis. The neurological pain resolved along with embolic and systemic signs of AM, and the patient has since been free of pain. CONCLUSION Multiple mononeuropathy is a possible symptom of AM and may precede onset of other embolic or systemic signs by several months.
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32
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Clinical Neuropathology practice guide 3-2014: combined nerve and muscle biopsy in the diagnostic workup of neuropathy - the Bordeaux experience. Clin Neuropathol 2014; 33:172-8. [PMID: 24618073 PMCID: PMC4021549 DOI: 10.5414/np300740] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2014] [Indexed: 11/18/2022] Open
Abstract
Simultaneous combined superficial peroneal nerve and peroneous brevis muscle biopsy, via the same cutaneous incision, allows examination of several tissue specimens and significantly improves the diagnosis of systemic diseases with peripheral nerve involvement. Vasculitides are certainly the most frequently diagnosed on neuro-muscular biopsies, but this procedure is also well advised to asses a diagnosis of sarcoidosis or amyloidosis. More occasionally, combined nerve and muscle biopsy may reveal an unpredicted diagnosis of cholesterol embolism, intra-vascular lymphoma, or enables complementary diagnosis investigations on mitochondrial cytopathy or storage disease.
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34
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Abstract
Vasculitis is a primary phenomenon in autoimmune diseases such as polyarteritis nodosa, Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, and essential mixed cryoglobulinemia. As a secondary feature vasculitis may complicate, for example, connective tissue diseases, infections, malignancies, and diabetes. Vasculitic neuropathy is a consequence of destruction of the vessel wall and occlusion of the vessel lumen of small epineurial arteries. Sometimes patients present with nonsystemic vasculitic neuropathy, i.e., vasculitis limited to peripheral nerves and muscles with no evidence of further systemic involvement. Treatment with corticosteroids, sometimes in combination with other immunosuppressants, is required to control the inflammatory process and prevent further ischemic nerve damage.
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Affiliation(s)
- Alexander F J E Vrancken
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre, Utrecht, The Netherlands
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