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Morishima R, Nagaoka U, Nagao M, Isozaki E. Chronic Brachial Plexus Neuritis That Developed into Typical Neuralgic Amyotrophy and Positively Responded to Immunotherapy. Intern Med 2018; 57:1021-1026. [PMID: 29269655 PMCID: PMC5919865 DOI: 10.2169/internalmedicine.9482-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Based on the hypothesis that autoimmunity plays a role in the pathogenesis of neuralgic amyotrophy (NA), immunotherapy is sometimes administered. Early intervention is recommended for a good prognosis. We herein report the case of a 55-year-old man who presented with neuralgia, weakness, and muscle atrophy in his right shoulder girdle and upper arm, which progressed for ten months following a marine sports accident. The patient was diagnosed with NA. His neurological deficits gradually improved after several courses of immunotherapy, suggesting that in addition to being effective for treating early-stage disease, immunotherapy may be effective for treating chronic cases.
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Affiliation(s)
- Ryo Morishima
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Utako Nagaoka
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Masahiro Nagao
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Eiji Isozaki
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
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Mahdi‐Rogers M, Brassington R, Gunn AA, van Doorn PA, Hughes RAC. Immunomodulatory treatment other than corticosteroids, immunoglobulin and plasma exchange for chronic inflammatory demyelinating polyradiculoneuropathy. Cochrane Database Syst Rev 2017; 5:CD003280. [PMID: 28481421 PMCID: PMC6481566 DOI: 10.1002/14651858.cd003280.pub5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a disease that causes progressive or relapsing and remitting weakness and numbness. It is probably caused by an autoimmune process. Immunosuppressive or immunomodulatory drugs would be expected to be beneficial. This review was first published in 2003 and has been updated most recently in 2016. OBJECTIVES To assess the effects of immunomodulatory and immunosuppressive agents other than corticosteroids, immunoglobulin, and plasma exchange in CIDP. SEARCH METHODS On 24 May 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4) in the Cochrane Library, MEDLINE, Embase, CINAHL, and LILACS for completed trials, and clinical trial registers for ongoing trials. We contacted the authors of the trials identified and other disease experts seeking other published and unpublished trials. SELECTION CRITERIA We sought randomised and quasi-randomised trials of all immunosuppressive agents, such as azathioprine, cyclophosphamide, methotrexate, ciclosporin, mycophenolate mofetil, and rituximab, and all immunomodulatory agents, such as interferon (IFN) alfa and IFN beta, in participants fulfilling standard diagnostic criteria for CIDP. We included all comparisons of these agents with placebo, another treatment, or no treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We wanted to measure the change in disability after one year as our primary outcome. Our secondary outcomes were change in disability after four or more weeks (from randomisation); change in impairment after at least one year; change in maximum motor nerve conduction velocity and compound muscle action potential amplitude after one year; and for participants who were receiving corticosteroids or intravenous immunoglobulin (IVIg), the amount of this medication given during at least one year after randomisation. Participants with one or more serious adverse events during the first year was also a secondary outcome. MAIN RESULTS Four trials fulfilled the selection criteria: one of azathioprine (27 participants), two of IFN beta-1a (77 participants in total) and one of methotrexate (60 participants). The risk of bias was considered low in the trials of IFN beta-1a and methotrexate but high in the trial of azathioprine. None of the trials showed significant benefit in any of the outcomes selected by their authors. The results of the outcomes which approximated most closely to the primary outcome for this review were as follows.In the azathioprine trial there was a median improvement in the Neuropathy Impairment Scale (scale range 0 to 280) after nine months of 29 points (range 49 points worse to 84 points better) in the azathioprine and prednisone treated participants compared with 30 points worse (range 20 points worse to 104 points better) in the prednisone alone group. There were no reports of adverse events.In a cross-over trial of IFN beta-1a with 20 participants, the treatment periods were 12 weeks. The median improvement in the Guy's Neurological Disability Scale (range 1 to 10) was 0.5 grades (interquartile range (IQR) 1.8 grades better to zero grade change) in the IFN beta-1a treatment period and 0.5 grades (IQR 1.8 grades better to 1.0 grade worse) in the placebo treatment period. There were no serious adverse events in either treatment period.In a parallel group trial of IFN beta-1a with 67 participants, none of the outcomes for this review was available. The trial design involved withdrawal from ongoing IVIg treatment. The primary outcome used by the trial authors was total IVIg dose administered from week 16 to week 32 in the placebo group compared with the IFN beta-1a groups. This was slightly but not significantly lower in the combined IFN beta-1a groups (1.20 g/kg) compared with the placebo group (1.34 g/kg, P = 0.75). There were four participants in the IFN beta-1a group and none in the placebo group with one or more serious adverse events, risk ratio (RR) 4.50 (95% confidence interval (CI) 0.25 to 80.05).The methotrexate trial had a similar design involving withdrawal from ongoing corticosteroid or IVIg treatment. At the end of the trial (approximately 40 weeks) there was no significant difference in the change in the Overall Neuropathy Limitations Scale, a disability scale (scale range 0 to 12), the median change being 0 (IQR -1 to 0) in the methotrexate group and 0 (IQR -0.75 to 0) in the placebo group. These changes in disability might have been confounded by the reduction in corticosteroid or IVIg dose required by the protocol. There were three participants in the methotrexate group and one in the placebo with one or more serious adverse events, RR 3.56 (95% CI 0.39 to 32.23). AUTHORS' CONCLUSIONS Low-quality evidence from randomised trials does not show significant benefit from azathioprine or interferon beta-1a and moderate-quality evidence from one randomised trial does not show significant benefit from a relatively low dose of methotrexate for the treatment of CIDP. None of the trials was large enough to rule out small or moderate benefit. The evidence from observational studies is insufficient to avoid the need for randomised controlled trials to discover whether these drugs are beneficial. Future trials should have improved designs, more sensitive outcome measures relevant to people with CIDP, and longer treatment durations.
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Affiliation(s)
| | - Ruth Brassington
- National Hospital for Neurology and NeurosurgeryQueen Square Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Angela A Gunn
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Pieter A van Doorn
- Erasmus University Medical CenterDepartment of NeurologyPO Box 2040RotterdamNetherlands3000 CA
| | - Richard AC Hughes
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
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Stangel M, Gold R, Pittrow D, Baumann U, Borte M, Fasshauer M, Hensel M, Huscher D, Reiser M, Sommer C. Treatment of patients with multifocal motor neuropathy with immunoglobulins in clinical practice: the SIGNS registry. Ther Adv Neurol Disord 2016; 9:165-79. [PMID: 27134672 DOI: 10.1177/1756285616629869] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The management of patients with multifocal motor neuropathy (MMN) under everyday clinical conditions has been insufficiently studied. We therefore collected comprehensive observational data on patients with MMN who received intravenous (IV) or subcutaneous (SC) immunoglobulins (IGs) as maintenance therapy. METHODS This was a prospective, noninterventional study (registry) in neurological centres (hospitals and offices) throughout Germany. RESULTS As of 1 December 2015, 80 patients with MMN were included (mean age 55.4 ± 9.8 years, 67% males, mean disease duration 10.7 ± 10.2 years). The affected limb regions were predominantly distal muscle groups of the upper extremities. On the inflammatory neuropathy cause and treatment (INCAT) scale, 94% of the patients had some disability in the arms and 61% in the legs. At inclusion, 98.8% received IVIG and 1.3% SCIG. Substantial variation was observed between IVIG treatment intervals (every 0.7 to 17.3 weeks) and dosage (0.2-2.1 g/kg body weight received during a single administration; mean monthly dosage, 0.9 g/kg body weight). However, the mean monthly dosage was steady over time. At 1-year follow up, improvement was seen in muscle strength, INCAT and quality of life (QoL) scores (SF-36 questionnaire). CONCLUSIONS The management of patients with MMN in everyday clinical practice demonstrates a wide range of absolute dosages and treatment intervals of IG, supporting the recommended practice of determining treatment dose on an individual patient basis. The improvements in muscle strength and reduction in disability, accompanied by increased QoL, strengthen the case for use of IG as a maintenance treatment for MMN.
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Affiliation(s)
- Martin Stangel
- Clinical Neuroimmunology and Neurochemistry, Department of Neurology, Hanover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
| | - Ralf Gold
- Department for Neurology, St. Josef-Hospital, Ruhr University Bochum, Germany
| | - David Pittrow
- Institute for Clinical Pharmacology, Medical Faculty, Technical University Dresden, Germany
| | - Ulrich Baumann
- Paediatric Pulmonology, Allergy and Neonatology, Hanover Medical School, Hanover, Germany
| | - Michael Borte
- Paediatric Rheumatology, Immunology and Infectiology, Hospital St. Georg, Leipzig, Germany
| | - Maria Fasshauer
- Paediatric Rheumatology, Immunology and Infectiology, Hospital St. Georg, Leipzig, Germany
| | | | - Dörte Huscher
- Epidemiology, German Rheumatism Research Centre, Berlin, Germany and; Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - Marcel Reiser
- PIOH - Praxis Internistische Onkologie, Hämatologie, Köln, Germany
| | - Claudia Sommer
- Department of Neurology, University Hospital Würzburg, Germany
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Robert F, Edan G, Nicolas G, Pouget J, Vial C, Antoine JC, Puget S. A retrospective study on the efficacy and safety of intraveinous immunoglobulin (Tegeline®) in patients with chronic inflammatory demyelinating polyneuropathy. Presse Med 2015; 44:e291-300. [DOI: 10.1016/j.lpm.2014.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 10/08/2014] [Accepted: 10/29/2014] [Indexed: 12/01/2022] Open
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Berger M, Allen JA. Optimizing IgG therapy in chronic autoimmune neuropathies: a hypothesis driven approach. Muscle Nerve 2015; 51:315-26. [PMID: 25418426 PMCID: PMC4357394 DOI: 10.1002/mus.24526] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 12/22/2022]
Abstract
Prolonged intravenous immunoglobulin (IVIG) therapy is used for the chronic autoimmune neuropathies chronic idiopathic demyelinating polyneuropathy and multifocal motor neuropathy, but the doses and treatment intervals are usually chosen empirically due to a paucity of data from dose-response studies. Recent studies of the electrophysiology and immunology of these diseases suggest that antibody-induced reversible dysfunction of nodes of Ranvier may play a role in conduction block and disability which responds to immunotherapy more rapidly than would be expected for demyelination or axonal damage per se. Clinical reports suggest that in some cases, the effects of each dose of IVIG may be transient, wearing-off before the next dose is due. These observations lead us to hypothesize that that therapeutic IgG acts by competing with pathologic autoantibodies and that individual patients may require different IgG levels for optimal therapeutic effects. Frequent IVIG dosing and weekly subcutaneous IgG have been tried as ways of continuously maintaining high serum IgG levels, resulting in stabilization of neuromuscular function in small case series. Frequent grip strength and disability measurements, performed by the patient at home and reported electronically, can be used to assess the extent and duration of responses to IgG doses. Individualization of IgG treatment regimens may optimize efficacy, minimize disability, and identify nonresponders.
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Affiliation(s)
- Melvin Berger
- CSL Behring, LLC., 1040 First Avenue, King of PrussiaPennsylvania, USA 19406
| | - Jeffrey A Allen
- University of MinnesotaMinneapolis, Minnesota, USA
- Northwestern UniversityChicago, Illinois, USA
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Furukawa T, Matsui N, Fujita K, Miyashiro A, Nodera H, Izumi Y, Shimizu F, Miyamoto K, Takahashi Y, Kanda T, Kusunoki S, Kaji R. Increased proinflammatory cytokines in sera of patients with multifocal motor neuropathy. J Neurol Sci 2014; 346:75-9. [DOI: 10.1016/j.jns.2014.07.059] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 07/02/2014] [Accepted: 07/28/2014] [Indexed: 02/08/2023]
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Miyashiro A, Matsui N, Shimatani Y, Nodera H, Izumi Y, Kuwabara S, Imai T, Baba M, Komori T, Sonoo M, Mezaki T, Kawamata J, Hitomi T, Kawamata J, Hitomi T, Kohara N, Arimura K, Hashimoto S, Arisawa K, Kusunoki S, Kaji R. Are multifocal motor neuropathy patients underdiagnosed? An epidemiological survey in Japan. Muscle Nerve 2014; 49:357-61. [PMID: 24741683 DOI: 10.1002/mus.23930] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Our objective was to do an epidemiologic survey of patients with multifocal motor neuropathy (MMN) in comparison with those with amyotrophic lateral sclerosis (ALS) in Japan. METHODS In this retrospective study, we examined 46 patients with MMN and 1,051 patients with ALS from major neuromuscular centers in Japan from 2005 to 2009. Diagnosis was based on the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) and the revised El Escorial criteria. The efficacy of intravenous immunoglobulin (IVIg) was also taken into consideration in the diagnosis of MMN. RESULTS The ratio of MMN to ALS patients (0–0.10) varied among the centers, but mostly converged to 0.05. The prevalence was estimated to be 0.29 MMN patients and 6.63 ALS patients per 100,000 population. CONCLUSIONS The frequency of MMN patients was around 1 out of 20 ALS patients, and MMN was possibly underdiagnosed in some centers.
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9
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Chan YC, Wilder-Smith E. Predicting treatment response in chronic, acquired demyelinating neuropathies. Expert Rev Neurother 2014; 6:1545-53. [PMID: 17078793 DOI: 10.1586/14737175.6.10.1545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic inflammatory demyelinating polyradiculopathy is an immune-mediated neuropathy that was first described approximately 30 years ago. Since that time an increasingly wide spectrum of chronic acquired demyelinating polyneuropathies exhibiting different phenotypes, clinical course and treatment responses to immunomodulatory treatment have been described. Several new therapeutic agents have been prescribed for such conditions, some with promising results. This review summarizes what is presently known about the clinical courses, treatment responses and predictors of response of the chronic inflammatory demyelinating polyradiculopathy subgroups.
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Affiliation(s)
- Yee-Cheun Chan
- National University Hospital, Division of Neurology, 5 Lower Kent Ridge Road, 119074 Sinagpore.
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10
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Broyles R, Rodden L, Riley P, Berger M. Variability in intravenous immunoglobulin G regimens for autoimmune neuromuscular disorders. Postgrad Med 2013; 125:65-72. [PMID: 23816772 DOI: 10.3810/pgm.2013.03.2619] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS We reviewed the intravenous immunoglobulin G (IVIG) dispensing records of a specialty pharmacy to characterize the IVIG treatment regimens used for chronic inflammatory demyelinating polyneuropathy (CIDP) and myasthenia gravis (MG) in community practice. METHODS Anonymized records were selected based on International Classification of Diseases, Ninth Revision (ICD-9) codes and IVIG treatment for > 1 month. Each patient's immunoglobulin G (IgG) dose per infusion (mg/kg/dose) was multiplied by the number of doses per month (30.5 days divided by the dosing interval in days) to yield the total monthly dose (mg/kg/month). Data were analyzed and summarized using descriptive statistics. RESULTS Forty-six patients (median age, 56.5 years; range, 8-86 years) fulfilled the inclusion criteria. Thirty-one patients with CIDP received IgG at 7- to 92-day intervals (mean [standard deviation (SD)], 28 [16] days). The mean (SD) IgG dose was 75 (60) g/dose, equivalent to 866 (623) mg/kg/dose and 1145 (778) mg/kg/month. Six patients with stable MG received IVIG or subcutaneous IgG at 3.5- to 61-day intervals (28 [20] days) at a mean (SD) IgG dose of 39 (15) g/dose, equivalent to 405 (108) mg/kg/dose and 783 (680) mg/kg/month. Nine patients with MG with acute exacerbations received IgG at 7- to 42-day intervals (22 [12] days) at a mean (SD) dose of 40 (21) g/dose, equivalent to 403 (172) mg/kg/dose and 641 (288) mg/kg/month. One patient with CIDP and 4 patients with MG were treated with weekly subcutaneous IgG injections. CONCLUSION Although patients with CIDP and MG are treated with mean total monthly IgG doses similar to those approved by the US Food and Drug Administration, the individual doses and intervals vary considerably, suggesting that physicians may be adjusting IgG dosing according to each patient's clinical condition and treatment response. Further study is necessary to determine the criteria used to adjust IgG treatment regimens and whether these adjustments optimize clinical outcomes while limiting overall costs.
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Affiliation(s)
- Randy Broyles
- National Director, Operations, BioRx, Cincinnati, OH, USA
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11
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Briani C, Cacciavillani M, Lucchetta M, Cecchin D, Gasparotti R. MR neurography findings in axonal multifocal motor neuropathy. J Neurol 2013; 260:2420-2. [PMID: 23893000 DOI: 10.1007/s00415-013-7052-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 07/14/2013] [Accepted: 07/15/2013] [Indexed: 12/01/2022]
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Multifocal motor neuropathy, multifocal acquired demyelinating sensory and motor neuropathy, and other chronic acquired demyelinating polyneuropathy variants. Neurol Clin 2013; 31:533-55. [PMID: 23642723 DOI: 10.1016/j.ncl.2013.01.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic acquired demyelinating neuropathies (CADP) constitute an important group of immune neuromuscular disorders affecting myelin. This article discusses CADP with emphasis on multifocal motor neuropathy, multifocal acquired demyelinating sensory and motor neuropathy, distal acquired demyelinating symmetric neuropathy, and less common variants. Although each of these entities has distinctive laboratory and electrodiagnostic features that aid in their diagnosis, clinical characteristics are of paramount importance in diagnosing specific conditions and determining the most appropriate therapies. Knowledge regarding pathogenesis, diagnosis, and management of these disorders continues to expand, resulting in improved opportunities for identification and treatment.
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Abstract
The identification of autoantibodies associated with dysimmune neuropathies was a major contribution to the characterization of peripheral nerve disorders, the understanding of their pathophysiology, and the clinical diagnosis of neuropathies. Antibodies directed to GM1, GQ1b, and disyalilated gangliosides, and anti-MAG antibodies are very useful in the diagnosis of acute or chronic motor or sensory-motor neuropathies with or without monoclonal IgM. Anti-onconeural anti-Hu and anti-CV2/CRMP antibodies allow when they are detected the diagnosis of paraneoplastic neuropathies. This chapter focuses on the description of these antibodies as diagnostic markers and on their immunopathogenesis. We give a background overview on the origin of these antibodies, their detection, and review those studies, which clearly show that these antibodies are capable of binding to the target tissues in peripheral nerve and thereby can exert a variety of pathophysiological effects. The corresponding electrophysiological and histological changes observed both in human and animal models are exemplified in order to get a better understanding of the immune mechanisms of these antibody-mediated neuropathies.
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Affiliation(s)
- Andreas Steck
- Department of Neurology, University Hospital Basel, Basel, Switzerland.
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Abstract
Multifocal motor neuropathy (MMN) is a rare disorder in which the symptoms are caused by persistent conduction block lesions. The mononeuropathy multiplex progresses over time with increasing axonal loss. The cause of the conduction blocks and axonal loss are not completely understood but immune mechanisms are involved and response to intravenous immunoglobulin has been established. The importance of MMN goes beyond its clinical incidence as the increasing understanding of the pathogenesis of this disorder has implications for other peripheral nerve diseases and for our knowledge of peripheral nerve biology.
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Affiliation(s)
- Ximena Arcila-Londono
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA
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Cartin-Ceba R, Peikert T, Specks U. Pathogenesis of ANCA-Associated Vasculitis. Curr Rheumatol Rep 2012; 14:481-93. [DOI: 10.1007/s11926-012-0286-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Nobile-Orazio E, Cocito D, Jann S, Uncini A, Beghi E, Messina P, Antonini G, Fazio R, Gallia F, Schenone A, Francia A, Pareyson D, Santoro L, Tamburin S, Macchia R, Cavaletti G, Giannini F, Sabatelli M. Intravenous immunoglobulin versus intravenous methylprednisolone for chronic inflammatory demyelinating polyradiculoneuropathy: a randomised controlled trial. Lancet Neurol 2012; 11:493-502. [DOI: 10.1016/s1474-4422(12)70093-5] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Vanhoutte EK, Faber CG, van Nes SI, Jacobs BC, van Doorn PA, van Koningsveld R, Cornblath DR, van der Kooi AJ, Cats EA, van den Berg LH, Notermans NC, van der Pol WL, Hermans MCE, van der Beek NAME, Gorson KC, Eurelings M, Engelsman J, Boot H, Meijer RJ, Lauria G, Tennant A, Merkies ISJ. Modifying the Medical Research Council grading system through Rasch analyses. ACTA ACUST UNITED AC 2011; 135:1639-49. [PMID: 22189568 PMCID: PMC3338921 DOI: 10.1093/brain/awr318] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The Medical Research Council grading system has served through decades for the evaluation of muscle strength and has been recognized as a cardinal feature of daily neurological, rehabilitation and general medicine examination of patients, despite being respectfully criticized due to the unequal width of its response options. No study has systematically examined, through modern psychometric approach, whether physicians are able to properly use the Medical Research Council grades. The objectives of this study were: (i) to investigate physicians’ ability to discriminate among the Medical Research Council categories in patients with different neuromuscular disorders and with various degrees of weakness through thresholds examination using Rasch analysis as a modern psychometric method; (ii) to examine possible factors influencing physicians’ ability to apply the Medical Research Council categories through differential item function analyses; and (iii) to examine whether the widely used Medical Research Council 12 muscles sum score in patients with Guillain–Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy would meet Rasch model's expectations. A total of 1065 patients were included from nine cohorts with the following diseases: Guillain–Barré syndrome (n = 480); myotonic dystrophy type-1 (n = 169); chronic inflammatory demyelinating polyradiculoneuropathy (n = 139); limb-girdle muscular dystrophy (n = 105); multifocal motor neuropathy (n = 102); Pompe's disease (n = 62) and monoclonal gammopathy of undetermined related polyneuropathy (n = 8). Medical Research Council data of 72 muscles were collected. Rasch analyses were performed on Medical Research Council data for each cohort separately and after pooling data at the muscle level to increase category frequencies, and on the Medical Research Council sum score in patients with Guillain–Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy. Disordered thresholds were demonstrated in 74–79% of the muscles examined, indicating physicians’ inability to discriminate between most Medical Research Council categories. Factors such as physicians’ experience or illness type did not influence these findings. Thresholds were restored after rescoring the Medical Research Council grades from six to four options (0, paralysis; 1, severe weakness; 2, slight weakness; 3, normal strength). The Medical Research Council sum score acceptably fulfilled Rasch model expectations after rescoring the response options and creating subsets to resolve local dependency and item bias on diagnosis. In conclusion, a modified, Rasch-built four response category Medical Research Council grading system is proposed, resolving clinicians’ inability to differentiate among its original response categories and improving clinical applicability. A modified Medical Research Council sum score at the interval level is presented and is recommended for future studies in Guillain–Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy.
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[Administration of intravenous immunoglobulins in neurology. An evidence-based consensus: update 2010]. DER NERVENARZT 2011; 82:415-6, 418, 420 passim. [PMID: 20577707 DOI: 10.1007/s00115-010-3059-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Our knowledge on the clinical efficacy of intravenous immunoglobulins (IVIg) in neurological diseases has greatly increased in the last 5 years. Liquid formulations with a higher concentration of IVIg have simplified administration. Despite a worldwide increase in plasma production it is still a valuable biological product which is why current indications must be continuously validated. Long-term efficacy of the preparation Gamunex could be demonstrated in patients with chronic inflammatory demyelinating polyneuropathy (CIDP). In acute myasthenic worsening a dose of 1 g IVIg/kg body weight appears to be sufficient for clinical stabilization. New indications, such as the postpolio syndrome or Alzheimer's disease are being explored in clinical trials. In addition to the consensus statement from 2004 the evidence for clinical use of IVIg has been re-evaluated and recommendations are given.
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Lehmann HC, Meyer Zu Horste G, Kieseier BC, Hartung HP. Pathogenesis and treatment of immune-mediated neuropathies. Ther Adv Neurol Disord 2011; 2:261-81. [PMID: 21179533 DOI: 10.1177/1756285609104792] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Immune-mediated neuropathies represent a heterogeneous spectrum of peripheral nerve disorders that can be classified according to time course, predominant involvement of motor/sensory fibers, distribution of deficits and paraclinical parameters such as electrophysiology and serum antibodies. In the last few years, significant advances have been achieved in elucidating underlying pathomechanisms, which made it possible to identify potential therapeutic targets. In this review, we discuss the latest development in pathogenesis and treatment of immune-mediated neuropathies.
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Michaud A, Delmont E, Jeandel PY, Desnuelle C. [Improvement of severe and intravenous immunoglobulin-dependent multifocal motor neuropathy with conduction block after long-term rituximab]. Rev Neurol (Paris) 2011; 167:916-20. [PMID: 21752414 DOI: 10.1016/j.neurol.2011.02.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Revised: 01/09/2011] [Accepted: 02/02/2011] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Some patients suffering from multifocal motor neuropathy with conduction blocks (MMNCB) are still disabled after treatment with intravenous immunoglobulin (IVIg). CASE REPORT We report the benefits of a combination of rituximab (RTX) and IVIg in the case of a 72-year-old man with MMNCB. DISCUSSION Despite an IVIg treatment, the patient had severe motor weakness of the four limbs which limited daily living activity. Azathioprine, mycophenolate mofetyl and cyclophosphamid did not improve the patient's status. Adjunction of rituximab to IVIg therapy increased muscle strength measured on MRC sum score and reduced disability evaluated on ONLS (Overall Neuropathy Limitation Scale) score in the long term (37 months). In spite of the improvement of his neurological status, the patient remained dependent on IVIg. CONCLUSION RTX could be proposed as a long-term complementary treatment for some severe cases of IVIg-dependent NMMBC. These results must be confirmed in a randomized controlled study.
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Affiliation(s)
- A Michaud
- Centre de référence des maladies neuromusculaires et SLA, hôpital de l'Archet, 1, route Saint-Antoine-de-Ginestière, BP 3979, 06202 Nice, cedex 3, France
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Fitzpatrick AM, Mann CA, Barry S, Brennan K, Overell JR, Willison HJ. An open label clinical trial of complement inhibition in multifocal motor neuropathy. J Peripher Nerv Syst 2011; 16:84-91. [DOI: 10.1111/j.1529-8027.2011.00328.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Misbah SA, Baumann A, Fazio R, Dacci P, Schmidt DS, Burton J, Sturzenegger M. A smooth transition protocol for patients with multifocal motor neuropathy going from intravenous to subcutaneous immunoglobulin therapy: an open-label proof-of-concept study. J Peripher Nerv Syst 2011; 16:92-7. [DOI: 10.1111/j.1529-8027.2011.00330.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Diagnostic and therapeutic challenges in chronic inflammatory demyelinating polyneuropathy and other immune-mediated neuropathies. Curr Opin Crit Care 2011; 17:101-5. [DOI: 10.1097/mcc.0b013e328342aded] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lange DJ, Nijjar R, Voustianiouk A, Seidel G, Panchal J, Wang AK. Do A-waves help predict intravenous immunoglobulin response in multifocal motor neuropathy without block? Muscle Nerve 2011; 43:537-42. [PMID: 21305570 DOI: 10.1002/mus.21914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2010] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Are there electrophysiological findings that predict response to intravenous immunoglobulin (IVIg) in patients with lower motor neuron (LMN) syndromes without multifocal conduction block (MCB)? METHODS We enrolled 9 patients with LMN syndromes without MCB to receive 18 weeks of IVIg therapy. Response was measured at weeks 2 and 18 using the Appel Amyotrophic Lateral Sclerosis (AALS) score (includes grip and pincer strength measures), ALS Functional Rating Scale (ALSFRS), and electrophysiological measures, including motor unit estimates (MUNEs). RESULTS No change occurred in AALS or ALSFRS scores posttreatment. Grip/pincer strength increased in 7 patients (P = 0.028) after initial treatment (responders); 2 showed no improvement (non-responders). No electrophysiological measure changed after treatment in either group but MUNEs trended higher (P = 0.055). "Abnormal A-waves" (complex, repetitive biphasic, or present in multiple nerves) occurred in pretreatment studies more often in responders (P = 0.028). DISCUSSION "Abnormal A-waves" may signal IVIg-responsive LMN syndromes even if conduction block is absent.
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Affiliation(s)
- Dale J Lange
- Department of Neurology, Division of Neuromuscular Disease, Mount Sinai School of Medicine, New York, New York, USA.
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Matà S, Borsini W, Ambrosini S, Toscani L, Barilaro A, Piacentini S, Sorbi S, Lolli F. IgM monoclonal gammopathy-associated neuropathies with different IgM specificity. Eur J Neurol 2011; 18:1067-73. [PMID: 21261794 DOI: 10.1111/j.1468-1331.2010.03345.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Antibodies directed against myelin-associated glycoprotein (MAG) are believed to be the most frequent biologic marker of the neuropathies associated with IgM monoclonal gammopathy of undetermined significance (MGUS). The objective of this study was to examine the prevalence of antiganglioside and/or sulfatide-positive patients and their clinical findings, including therapeutic response, compared to anti-MAG-positive or seronegative patients. METHODS We prospectively followed 46 patients with MGUS who were diagnosed in our tertiary referral centers for polyneuropathy since 1997. All patients underwent nerve conduction studies and were tested for anti-MAG, gangliosides, and sulfatide antibodies. All the anagraphic and clinical data (including symptoms, disability scale, therapy, secondary malignancy development) were recorded in a database and compared between three patients' groups (anti-MAG-positive; antiganglioside/sulfatide-positive; no reactivity). RESULTS Anti-MAG reactivity was present in 17 (37%) patients; other 17 patients (37%) had antiganglioside/sulfatide reactivity and 12 (26%) had no reactivity. Patients with antiganglioside/sulfatide positivity, although heterogeneous by a clinical and neurophysiological point of view, had the most severe neuropathic manifestations and a higher disability score at nadir (P < 0.001). These patients had a better response to both intravenous immunoglobulin therapy and rituximab. CONCLUSIONS Our results suggest that antiganglioside/sulfatide-positive patients form a relevant portion of patients with MGUS-associated polyneuropathy seen in tertiary care centers and should be considered in future studies on treatment response.
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Affiliation(s)
- S Matà
- Neurology Department, University Hospital of Careggi, Firenze Neurology Department, S.M. Annunziata Hospital, Firenze, Italy.
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Straver DC, van den Berg LH, van den Berg-Vos RM, Franssen H. Activity-dependent conduction block in multifocal motor neuropathy. Muscle Nerve 2010; 43:31-6. [DOI: 10.1002/mus.21843] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Nobile-Orazio E, Gallia F, Tuccillo F, Terenghi F. Chronic inflammatory demyelinating polyradiculoneuropathy and multifocal motor neuropathy: treatment update. Curr Opin Neurol 2010; 23:519-23. [DOI: 10.1097/wco.0b013e32833dd218] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Murata Y, Okamoto T, Kondo Y, Chihara N, Furusawa Y, Murata M. [Monthly low-dose immunoglobulin infusion as a maintenance therapy for multifocal motor neuropathy may reduce allergic adverse effects: a case report]. Rinsho Shinkeigaku 2010; 50:561-5. [PMID: 20803965 DOI: 10.5692/clinicalneurol.50.561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 41-year-old man with multiple motor neuropathy developed weakness of the left hand at the age of 35 years. The weakness gradually progressed to his right hand. High-dose intravenous immunoglobulin (IVIg) therapy (0.4 g/kg for 5 consecutive days) improved the muscle weakness in the hands but led to the development of generalized severe pompholyx that spread to the skin over the entire body. Because muscle weakness of the hands worsened several months after IVIg therapy, we attempted another course of IVIg therapy. However, antiallergic agents and oral corticosteroids did not suppress the pompholyx induced by the high-dose IVIg. Hence, the treatment was switched to low-dose immunoglobulin therapy (0.4 g/kg for one day) once every month. After more than 8 months of low-dose therapy, only mild form of pompholyx remained and the muscle strength was maintained without further deterioration.
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Affiliation(s)
- Yoshiko Murata
- Department of Neurology, National Center Hospital of Neurology and Psychiatry
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Abstract
Antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) comprises a group of systemic inflammatory vasculitides associated with circulating autoantibodies directed against the neutrophil granule components proteinase 3 and myeloperoxidase. ANCA interact with their target antigens on cytokine primed neutrophils, causing neutrophil activation via several signaling pathways that culminates in endothelial interaction, degranulation, cytokine production, and endothelial and tissue damage. The presence of autoantibodies implies the assistance of autoreactive T-helper cells and B cells, and a failure of regulatory mechanisms. This article reviews the current evidence for the pathogenic mechanisms culminating in autoantibody production, the effects of ANCA-neutrophil and neutrophil-endothelial interactions, and the mechanisms of tissue damage.
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Affiliation(s)
- Julia Flint
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK
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De Sousa EA. Chronic inflammatory demyelinating polyneuropathy: diagnosis and management. Expert Rev Clin Immunol 2010; 6:373-80. [PMID: 20441424 DOI: 10.1586/eci.10.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the course of 8 weeks, a 50-year-old man developed progressive bilateral leg and arm weakness, with numbness and tingling of the feet and hands. His symptoms persisted for 6 months, with impaired manual dexterity, arm weakness when brushing his teeth, tripping when walking, inability to climb stairs and gait imbalance. On examination, there is mild proximal and distal weakness of the upper and lower extremity muscles, length-dependent sensory loss of vibratory perception and joint position sense, areflexia, positive Romberg test and steppage gait with bilateral foot drop. Motor nerve conduction studies of the arms and legs show partial conduction blocks in several nerves with nonuniform slowing, and sensory responses are absent in the hands, however, normal sural responses are noted. Lumbar puncture reveals acellular cerebrospinal fluid with elevated protein. After 2 months following treatment, his strength and gait improved significantly, and his sensory symptoms resolved.
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Affiliation(s)
- Eduardo A De Sousa
- Neuromuscular Medicine, Department of Neurology, Jefferson Medical College, Thomas Jefferson University, 900 Walnut Street, Ste 200, Philadelphia, PA 19107, USA.
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Manganelli F, Pisciotta C, Iodice R, Dubbioso R, Santoro L. Reply. Muscle Nerve 2010. [DOI: 10.1002/mus.21646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Donofrio PD, Berger A, Brannagan TH, Bromberg MB, Howard JF, Latov N, Quick A, Tandan R. Consensus statement: The use of intravenous immunoglobulin in the treatment of neuromuscular conditions report of the aanem AD HOC committee. Muscle Nerve 2009; 40:890-900. [DOI: 10.1002/mus.21433] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Nobile-Orazio E, Terenghi F, Cocito D, Gallia F, Casellato C. Oral methotrexate as adjunctive therapy in patients with multifocal motor neuropathy on chronic IVIg therapy. J Peripher Nerv Syst 2009; 14:203-5. [DOI: 10.1111/j.1529-8027.2009.00233.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Stangel M, Hartung HP, Gold R, Kieseier BC. [The significance of intravenous immunoglobulin in treatment of immune-mediated polyneuropathies]. DER NERVENARZT 2009; 80:678-687. [PMID: 19139838 DOI: 10.1007/s00115-008-2631-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Long-term treatment of immune-mediated polyneuropathies remains difficult. For acute polyneuritis, or Guillain-Barré syndrome, the established standard therapy utilizes high doses of polyvalent intravenous immunoglobulins (IVIG). A recently published randomized placebo-controlled study of patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) showed IVIG to be clinically effective also for this disorder in both short and long term. This survey presents data of this so-called ICE study ("Intravenous immune globulin for the treatment of chronic inflammatory demyelinating polyradiculoneuropathy"). It also discusses the value of IVIG in the treatment of immune-mediated polyneuropathies.
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Affiliation(s)
- M Stangel
- Klinik für Neurologie, Medizinische Hochschule Hannover, Hannover, Deutschland
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Dimberg EL. Treatment of multifocal motor neuropathy with immunoglobulin: does route of administration matter? Eur J Neurol 2009; 16:553-4. [DOI: 10.1111/j.1468-1331.2009.02565.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Arai M, Kusunoki S. [A case of multifocal motor neuropathy with IgM lambda anti-GM1 antibody and IgM kappa paraprotein reacting exclusively with GM2]. Rinsho Shinkeigaku 2009; 49:123-126. [PMID: 19348179 DOI: 10.5692/clinicalneurol.49.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A 57-year-old previously healthy woman visited our clinic complaining of frequent muscle cramps and progressive weakness in the hands and fingers for 3 years. On examination, cranial nerves were unremarkable. There were moderate weakness and mild muscle wasting with fasciculation in the left thumb flexor and interossei on both sides. Tendon reflexes were hypoactive. There were no pathologic reflexes or sensory deficit. The cerebrospinal fluid was unremarkable. Nerve conduction studies demonstrated conduction block in the right ulnar nerve. Compound muscle action potential in the left median nerve was low-normal. Distal motor latencies, motor and sensory nerve conduction velocities were normal in all nerves tested. A diagnosis of multifocal motor neuropathy was made. Two courses of intravenous immunoglobulin infusion gave no beneficial effects. The patient had IgM kappa monoclonal gammopathy of undetermined significance. Her serum IgM reacted with GM2, GM1, and GA1 but not with GD1a, GD1b, GD3, GalNAc-GD1a, GT1b, GQ1b, galactocerebroside, or sulfated glucuronyl paragloboside. IgM kappa paraprotein reacted exclusively with GM2. Only IgM lambda bound to GM1 and GA1, suggesting the possibility that another paraprotein, though undetectable by immunoelectrohoresis, had a reactivity with GM1 and GA1. This case showed previously unreported antigenic specificity of paraproteins in cases of MMN.
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Affiliation(s)
- Motomi Arai
- Department of Neurology, Seirei Mikatahara General Hospital
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Randomised controlled trial of methotrexate for chronic inflammatory demyelinating polyradiculoneuropathy (RMC trial): a pilot, multicentre study. Lancet Neurol 2009; 8:158-64. [DOI: 10.1016/s1474-4422(08)70299-0] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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How to assess new drugs for neuropathies: advances in trial design and methodology. Curr Opin Neurol 2008; 21:519-26. [DOI: 10.1097/wco.0b013e32830f1e3b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Stangel M. New advances in the treatment of neurological diseases using high dose intravenous immunoglobulins. Ther Adv Neurol Disord 2008; 1:52-61. [PMID: 21180569 PMCID: PMC3002549 DOI: 10.1177/1756285608095747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Since the incidental discovery in 1981 that intravenous immunoglobulins (IVIg) are immunomodulatory, they have been investigated in a large number of putative autoimmune diseases. This has led to licensing for idiopathic thrombocytopenic purpura, Kawasaki disease, and in neurological disorders for Guillain-Barré syndrome (GBS). Although not licensed, randomized controlled trials have also shown IVIg efficacy in other neuroimmunological diseases such as multifocal motor neuropathy (MMN), chronic inflammatory demyelinating neuropathy (CIDP), myasthenia gravis, dermatomyositis, and stiff-person syndrome. However, other indications are currently being explored including Alzheimer's disease, postpolio syndrome, and narcolepsy. There are even reports from experimental studies in stroke. The results of recently published clinical trials in both the classical neuroimmunological disorders as well as for new indications are reported and their role in clinical practice is discussed.
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Affiliation(s)
- Martin Stangel
- Department of Neurology Hannover Medical School Carl-Neuberg-Str. 1 30625 Hannover Germany.
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Axelson HW, Oberg G, Askmark H. No benefit of treatment with cyclophosphamide and autologous blood stem cell transplantation in multifocal motor neuropathy. Acta Neurol Scand 2008; 117:432-4. [PMID: 18081911 DOI: 10.1111/j.1600-0404.2007.00970.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Patients with multifocal motor neuropathy (MMN) usually respond to intravenous immunoglobulin (IVIG), but because of the short-lasting effect the treatment must be given repeatedly. Remission after treatment with high-dose cyclophosphamide has recently been reported in one patient refractory to IVIG. CASE REPORT Here we report on a patient who responded to IVIG, but temporarily deteriorated dramatically after treatment with high-dose cyclophosphamide and autologous blood stem cell transplantation. Today the situation is the same as before the treatment with cyclophosphamide and blood stem cell transplantation, i.e. IVIG is given every 4 weeks. CONCLUSION Our patient did not benefit from the treatment with high-dose cyclophosphamide and autologous blood stem cell transplantation. The effect of treatment with high-dose cyclophosphamide in MMN seems to be difficult to predict and that should be paid attention to if this type of treatment is considered.
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Affiliation(s)
- H W Axelson
- Department of Neurophysiology, University Hospital, Uppsala, Sweden.
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Lehmann HC, Hoffmann FR, Fusshoeller A, Meyer zu Hörste G, Hetzel R, Hartung HP, Schroeter M, Kieseier BC. The clinical value of therapeutic plasma exchange in multifocal motor neuropathy. J Neurol Sci 2008; 271:34-9. [PMID: 18485370 DOI: 10.1016/j.jns.2008.02.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Revised: 01/18/2008] [Accepted: 02/27/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Although there is evidence for a pathogenic role of humoral factors in multifocal motor neuropathy (MMN), plasma exchange (PE) is assumed to be an ineffective treatment. We set out to elucidate possible reasons for this apparent contradiction. METHODS A retrospective analysis of seven patients with MMN, who underwent 4 to 18 sessions of PE. Clinical response, electrophysiological parameter and anti-ganglioside antibody titers were reviewed. RESULTS Two patients, who had anti-ganglioside antibodies, exhibited transient clinical responses to PE, manifested by improved neurological function. Whereas electrophysiological parameters continued to worsen in all patients, anti-ganglioside antibody titers declined during PE, but increased after PE. CONCLUSION PE is of limited therapeutic value in patients with MMN, who do not respond to established treatment options. It may only be useful as an adjunctive treatment in a subset of patients. The transient decrease of anti-ganglioside-antibodies titers suggests that pathogenic humoral factors in MMN are only temporarily reduced. Further, PE treatment alone is insufficient to prevent axons from continuing degeneration, which may explain the failure of PE to substantially influence the disease course of patients with MMN.
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Affiliation(s)
- Helmar C Lehmann
- Department of Neurology, Heinrich-Heine-University of Düsseldorf, Germany.
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Abstract
PURPOSE OF REVIEW Two disorders, Lewis-Sumner syndrome and multifocal motor neuropathy, are defined by the demonstration of conduction block. These two entities have been intertwined since their description but there are important distinctions between them. It is therefore timely to reconsider these disorders and the physiologic process that defines them. RECENT FINDINGS Understanding of the pathophysiology of conduction block has evolved with better understanding of the structure of the node of Ranvier and surrounding apparatus. Axonal excitability studies have begun to give insights into why multifocal motor neuropathy has only motor conduction block. The many published criteria for conduction block vary in sensitivity and specificity and the electromyographer must be aware of the difficulties in determining physiologic block. The distinctions between Lewis-Sumner syndrome and multifocal motor neuropathy have become increasingly clear. Evidence suggests that Lewis-Sumner syndrome is a multifocal variant of chronic inflammatory demyelinating polyneuropathy but that multifocal motor neuropathy is distinct. SUMMARY It is important to recognize the distinctions between these disorders, not only because there are important therapeutic issues, but also because a true understanding of the nature of these illnesses will only be accomplished if the overlaps and differences are carefully considered.
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Affiliation(s)
- Richard Alan Lewis
- Wayne State University School of Medicine, Department of Neurology, Detroit, Michigan 48201, USA.
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Bibliography. Current world literature. Neuro-muscular diseases: nerve. Curr Opin Neurol 2007; 20:600-4. [PMID: 17885452 DOI: 10.1097/wco.0b013e3282efeb3b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Leger JM, Vargas S, Lievens I. Efficacy of Intravenous Immunoglobulin in Multifocal Motor Neuropathy. Ann N Y Acad Sci 2007; 1110:248-55. [PMID: 17911439 DOI: 10.1196/annals.1423.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Multifocal motor neuropathy is a distinct entity, whose treatment differs from that of other chronic immune-mediated neuropathies, mainly chronic inflammatory demyelinating polyradiculoneuropathy, and its variant, multifocal acquired demyelinating sensory and motor neuropathy, although they share some electrophysiological characteristics. From the first descriptions, intravenous immunoglobulins (IVIg) have been considered to be the gold standard of treatment for multifocal motor neuropathy. However, if the effectiveness of IVIg has been confirmed by several randomized, double-blind, placebo-controlled trials, only a few patients experience persistent improvement after a single or few courses of therapy, and the long-term efficacy of IVIg in this disease is currently debated. Consequently, there is a need for new therapeutic strategies that focus on the effects and the costs of this therapy over long-term follow-up.
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Affiliation(s)
- Jean-Marc Leger
- Reference Center for Neuromuscular Diseases, Bâtiment Babinski, Hôpital de la Salpêtrière, 47 boulevard de l'Hôpital, 75651 Paris cedex 13, France.
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Abstract
Multifocal motor neuropathy with persistent conduction blocks was first specifically identified in 1986. Its major criterion is conduction blocks in motor nerves only. Clinically, this is a multifocal, thus asymmetric, neuropathy that begins and predominant touches upper limbs; it especially affects men after the age of 50 years and has a chronic course with relapses. Approximately 40-50% of patients also have IgM serum antibodies directed against GM1 ganglioside. There are no other laboratory criteria, although moderately high protein levels are found in cerebrospinal fluid. Its course is unpredictable, because the neuropathy may remain limited to one or two motor nerves or extend progressively to all the motor nerves of all four limbs. In general, there is no damage to sensory or cranial nerves or to the autonomic or central nervous systems. Intravenous polyvalent immunoglobulins at high doses are remarkably effective in the short term in 70 to 80% of cases. Corticosteroids and plasma exchange are generally ineffective and may aggravate the neuropathy. The long-term efficacy of intravenous immunoglobulins in delaying motor decline and axon loss in the affected motor nerves is controversial. No information is currently available about the long-term efficacy of other immunomodulatory treatment.
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Affiliation(s)
- Jean-Marc Léger
- Centre de Référence Maladies Neuromusculaires Rares, CHU Pitié-Salpêtrière, Paris.
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