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Nakane S, Matsuo H, Nakatsuji Y. Immunological and therapeutic insights in autoimmune autonomic ganglionopathy: What is the position of apheresis in immunotherapy? Transfus Apher Sci 2024; 63:103967. [PMID: 38959810 DOI: 10.1016/j.transci.2024.103967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
Autoimmune autonomic ganglionopathy (AAG) is characterized by various autonomic and extra-autonomic symptoms and is caused by autoantibodies against nicotinic acetylcholine receptors present in the autonomic ganglia (ganglionic acetylcholine receptor, gAChR), requiring immediate and aggressive intervention to prevent the exacerbation of symptoms. However, there is currently no internationally accepted standard of care for the immunotherapy of AAG, including apheresis. Although the rationale for the use of plasma exchange (PLEX) in AAG is strong, whereby pathogenic gAChR antibodies are removed, its overall impact on patient outcomes is not well-established. Based on previous case reports and small case series studies, we provide a comprehensive overview of the challenges and uncertainties surrounding the use of PLEX for the management of AAG and provide current practice recommendations to guide treatment decisions.
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Affiliation(s)
- Shunya Nakane
- Department of Neurology, Faculty of Medicine, University of Toyama, Toyama, Japan.
| | - Hidenori Matsuo
- Department of Neurology, National Hospital Organization Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Yuji Nakatsuji
- Department of Neurology, Faculty of Medicine, University of Toyama, Toyama, Japan
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Hayashi T, Nakane S, Mukaino A, Higuchi O, Yamakawa M, Matsuo H, Kimura K. Effectiveness of treatment for 31 patients with seropositive autoimmune autonomic ganglionopathy in Japan. Ther Adv Neurol Disord 2022; 15:17562864221110048. [PMID: 35966941 PMCID: PMC9364197 DOI: 10.1177/17562864221110048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 06/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Autoimmune autonomic ganglionopathy (AAG) is characterized by serum
autoantibodies against the ganglionic acetylcholine receptor (gAChR).
Immunomodulatory treatments may alleviate AAG symptoms, but the most
appropriate treatment strategy is unclear. Objective: This study aimed to confirm the effectiveness of treatments, particularly
immunotherapy, in patients with seropositive AAG in Japan, as well as to
determine the most effective treatment and the best assessment method for
clinical response to treatment. Methods: We collected data from a previous cohort study of patients with seropositive
AAG. The clinical autonomic and extra-autonomic symptoms were objectively
counted and subjectively assessed using the modified Composite Autonomic
Symptom Score. Post-treatment changes in the gAChR antibody level were
evaluated. Results: Thirty-one patients received immunotherapy. Among them, 19 patients received
intravenous methylprednisolone; 27, intravenous immunoglobulin; 3, plasma
exchange; 18, oral steroids; 2, tacrolimus; 1, cyclosporine; and 1,
mycophenolate mofetil. Patients who received immunotherapy showed
improvements in the total number of symptoms (from 6.2 ± 2.0 to 5.1 ± 2.0)
and modified Composite Autonomic Symptom Score (from 37.4 ± 15.3 to
26.6 ± 12.8). Orthostatic intolerance, sicca, and gastrointestinal symptoms
were ameliorated by immunotherapy. Immunotherapy decreased the antibody
levels (gAChRα3 antibodies, from 2.2 ± 0.4 to 1.9 ± 0.4,
p = 0.08; gAChRβ4 antibodies, from 1.6 ± 0.1 to 1.0 ± 0.2,
p = 0.002), but antibody levels increased in 10
patients despite immunotherapy. The rate of improvement in the total number
of symptoms was higher in patients with combined therapy than in patients
with non-combined therapy (70.7% vs 28.6%). Conclusions: The scores in many items on the rating scale decreased after immunotherapy in
patients with seropositive AAG, particularly in the combined immunotherapy
group. However, more accurate assessment scales for clinical symptoms and
multicenter randomized, placebo-controlled prospective studies are warranted
to establish future treatment strategies.
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Affiliation(s)
| | - Shunya Nakane
- Department of Neurology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo 113-8602, Japan
| | - Akihiro Mukaino
- Department of Japanese Oriental Medicine, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Osamu Higuchi
- Department of Clinical Research, NHO Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Makoto Yamakawa
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hidenori Matsuo
- Department of Neurology, NHO Nagasaki Hospital, Nagasaki, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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Gavrilova N, Kamaeva E, Ignatova M, Ryabkova V, Lukashenko M, Churilov L, Shoenfeld Y. Intravenouse immunoglobuline in dysautonomia. Clin Immunol 2022; 240:109039. [DOI: 10.1016/j.clim.2022.109039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/01/2022] [Accepted: 05/07/2022] [Indexed: 11/03/2022]
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Nakane S, Mukaino A, Ihara E, Ogawa Y. Autoimmune gastrointestinal dysmotility: the interface between clinical immunology and neurogastroenterology. Immunol Med 2020; 44:74-85. [DOI: 10.1080/25785826.2020.1797319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Shunya Nakane
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan
| | - Akihiro Mukaino
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan
| | - Eikichi Ihara
- Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Bouxin M, Schvartz B, Mestrallet S, Debrumetz A, Hentzien M, Tabary T, Cohen R, Nicolas G, Bani-Sadr F. Rituximab treatment in seronegative autoimmune autonomic neuropathy and autoimmune autonomic ganglionopathy: Case-report and literature review. J Neuroimmunol 2018; 326:28-32. [PMID: 30468952 DOI: 10.1016/j.jneuroim.2018.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/13/2018] [Accepted: 11/13/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Autoimmune autonomic ganglionopathy (AAG) is a rare disease with no well-established treatment. Until recently, AAG could be seropositive (50 to 60% of patients) or seronegative for ganglionic (α3-type) nicotinic acetylcholine receptor (Gα3NAChR) antibodies. In early 2018, the two forms of the disease were distinguished, separating seropositive from seronegative ones, designating this latter form "seronegative autoimmune autonomic neuropathy" (SAAN). Most described treatments are plasma exchange (PE) and intravenous immunoglobulin (IVIG). However in some cases with no or small benefit, other immunomodulatory therapies, such as rituximab have been reported. We report the case of a 24-year-old female patient successfully treated for SAAN with rituximab and steroids after IVIG and PE failure. We also provide a review of case-reports reporting rituximab treatment for both SAAN and AAG. METHODS To identify articles reporting SAAN and AAG treatment with rituximab, we searched the PubMed database using the terms "autoimmune autonomic ganglionopathy", "autoimmune autonomic neuropathy" or "seronegative autoimmune autonomic neuropathy" and "rituximab". RESULTS Including our patient, nine cases have been described in the literature (4 SAAN and 5 AAG). Rituximab had a significant positive effect in 2 out of 4 SAAN and all 5 AAG cases, used alone or in association with other etiologic treatments. CONCLUSION Our study suggests rituximab (alone or in association with other treatments) could provide efficacy in both SAAN and AAG when PE and/or IVIG are not effective enough.
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Affiliation(s)
- M Bouxin
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - B Schvartz
- Department of Nephrology and Transplantation, Reims Teaching Hospitals, Reims, France
| | - S Mestrallet
- Department of Internal Medicine and Infectious Diseases, CH de Charleville-Mézières, Charleville-Mézières, France
| | - A Debrumetz
- Department of Nephrology and Transplantation, Reims Teaching Hospitals, Reims, France
| | - M Hentzien
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - T Tabary
- Immunology Laboratory, Reims Teaching Hospitals, Reims, France
| | - R Cohen
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - G Nicolas
- Department of Neurology, Assistance Publique des Hôpitaux de Paris, Raymond-Poincaré Hospital, Garches, France
| | - F Bani-Sadr
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France; University of Reims Champagne-Ardenne, EA-4684 / SFR CAP-SANTE, Reims F-51095, France.
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Nakane S, Mukaino A, Higuchi O, Watari M, Maeda Y, Yamakawa M, Nakahara K, Takamatsu K, Matsuo H, Ando Y. Autoimmune autonomic ganglionopathy: an update on diagnosis and treatment. Expert Rev Neurother 2018; 18:953-965. [PMID: 30352532 DOI: 10.1080/14737175.2018.1540304] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder that leads to autonomic failure. The disorder is associated with autoantibodies to the ganglionic nicotinic acetylcholine receptor (gAChR). We subsequently reported that AAG is associated with an overrepresentation of psychiatric symptoms, sensory disturbance, autoimmune diseases, and endocrine disorders. Area covered: The aim of this review was to describe AAG and highlight its pivotal pathophysiological aspects, clinical features, laboratory examinations, and therapeutic options. Expert commentary: AAG is a complex neuroimmunological disease, these days considered as an autonomic failure with extra-autonomic manifestations (and various limited forms). Further comprehension of the pathophysiology of this disease is required, especially the mechanisms of the extra-autonomic manifestations should be elucidated. There is the possibility that the co-presence of antibodies that were directed against the other subunits in both the central and peripheral nAChRs in the serum of the AAG patients. Some patients improve with immunotherapies such as IVIg and/or corticosteroid and/or plasma exchange. 123I-MIBG myocardial scintigraphy may be a useful tool to monitor the therapeutic effects of immunotherapies.
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Affiliation(s)
- Shunya Nakane
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan.,b Department of Molecular Neurology and Therapeutics , Kumamoto University Hospital , Kumamoto , Japan
| | - Akihiro Mukaino
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan.,b Department of Molecular Neurology and Therapeutics , Kumamoto University Hospital , Kumamoto , Japan
| | - Osamu Higuchi
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Mari Watari
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Yasuhiro Maeda
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Makoto Yamakawa
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Keiichi Nakahara
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Koutaro Takamatsu
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Hidenori Matsuo
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Yukio Ando
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
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Nakane S, Mukaino A, Ando Y. [The interface between the immune system and autonomic nervous system]. ACTA ACUST UNITED AC 2017; 40:352-360. [PMID: 29238017 DOI: 10.2177/jsci.40.352] [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: 11/15/2022]
Abstract
The nervous system and the immune system are two major systems in human body. Although it was revealed these two systems correlated, the control of immune cell dynamics by the nervous system has come to draw a lot of attention at the present time. Recent advances in basic and preclinical science reveal that reflex neural circuits inhibit the production of cytokines and inflammation in several animal models. One well-characterized cytokine-inhibiting mechanism, termed the "inflammatory reflex", is dependent upon vagus nerve stimulation that inhibits cytokine production and attenuates the inflammation. And the mechanism for controlling lymphocyte trafficking becomes clear, and molecular basis of immune regulation by the nervous system was reported. On the other hand, the nervous system is protected from the invasion of harmful agents by the barrier. However, there are neuroimmunological disorders, which is associated with autoimmunity, tumor immunity, and infection immunity. Autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder that leads to widespread autonomic manifestations, in which autoantibodies to ganglionic nicotinic acetylcholine receptors play a central role. Previously, we elucidated the prevalence of extra-autonomic manifestations in patients with AAG. It is necessary to establish the new systems for the detection of autoantibodies to other subunits of acetylcholine receptor.
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Affiliation(s)
- Shunya Nakane
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University.,Asian Neurological Intractable Diseases Research and Clinic (AIDReC), Graduate School of Medical Sciences, Kumamoto University
| | - Akihiro Mukaino
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University.,Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University
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Nakane S, Higuchi O, Koga M, Kanda T, Murata K, Suzuki T, Kurono H, Kunimoto M, Kaida KI, Mukaino A, Sakai W, Maeda Y, Matsuo H. Clinical features of autoimmune autonomic ganglionopathy and the detection of subunit-specific autoantibodies to the ganglionic acetylcholine receptor in Japanese patients. PLoS One 2015; 10:e0118312. [PMID: 25790156 PMCID: PMC4366081 DOI: 10.1371/journal.pone.0118312] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 01/14/2015] [Indexed: 01/08/2023] Open
Abstract
Autoimmune autonomic ganglionopathy (AAG) is a rare acquired channelopathy that is characterized by pandysautonomia, in which autoantibodies to ganglionic nicotinic acetylcholine receptors (gAChR) may play a central role. Radioimmunoprecipitation (RIP) assays have been used for the sensitive detection of autoantibodies to gAChR in the serum of patients with AAG. Here, we developed luciferase immunoprecipitation systems (LIPS) to diagnose AAG based on IgGs to both the α3 and β4 gAChR subunits in patient serum. We reviewed the serological and clinical data of 50 Japanese patients who were diagnosed with AAG. With the LIPS testing, we detected anti-α3 and -β4 gAChR antibodies in 48% (24/50) of the patients. A gradual mode of onset was more common in the seropositive group than in the seronegative group. Patients with AAG frequently have orthostatic hypotension and upper and lower gastrointestinal tract symptoms, with or without anti-gAChR. The occurrence of autonomic symptoms was not significantly different between the seropositive and seronegative group, with the exception of achalasia in three patients from the seropositive group. In addition, we found a significant overrepresentation of autoimmune diseases in the seropositive group and endocrinological abnormalities as an occasional complication of AAG. Our results demonstrated that the LIPS assay was a useful novel tool for detecting autoantibodies against gAChR in patients with AAG.
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Affiliation(s)
- Shunya Nakane
- Department of Clinical Research, Nagasaki Kawatana Medical Center, Nagasaki, Japan; Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Osamu Higuchi
- Department of Clinical Research, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Kenya Murata
- Department of Neurology, Wakayama Medical University, Wakayama, Japan
| | - Takashi Suzuki
- Department of Neurology, Joetsu General Hospital, Niigata, Japan
| | - Hiroko Kurono
- Department of Neurology, Saiseikai Kanagawa Prefecture Hospital, Kanagawa, Japan
| | - Masanari Kunimoto
- Department of Neurology, Saiseikai Kanagawa Prefecture Hospital, Kanagawa, Japan
| | - Ken-ichi Kaida
- Division of Neurology, Department of Internal Medicine 3, National Defense Medical College, Saitama, Japan
| | - Akihiro Mukaino
- Department of Clinical Neuroscience and Neurology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Waka Sakai
- Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Yasuhiro Maeda
- Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Hidenori Matsuo
- Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
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