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Motte J, Fisse AL, Köse N, Grüter T, Mork H, Athanasopoulos D, Fels M, Otto S, Siglienti I, Schneider-Gold C, Hellwig K, Yoon MS, Gold R, Pitarokoili K. Treatment response to cyclophosphamide, rituximab, and bortezomib in chronic immune-mediated sensorimotor neuropathies: a retrospective cohort study. Ther Adv Neurol Disord 2021; 14:1756286421999631. [PMID: 33747132 PMCID: PMC7940507 DOI: 10.1177/1756286421999631] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 12/13/2022] Open
Abstract
Background: Up to 20% of patients with chronic immune-mediated sensorimotor neuropathies (CIN) do not respond adequately to first-line therapies. However, studies on further treatment are scarce. Methods: We analyzed retrospectively 200 CIN patients regarding disease characteristics and response to therapy with cyclophosphamide (CYP), rituximab (RTX), and bortezomib (BTZ). Treatment response was defined as improvement or stabilization of inflammatory neuropathy cause and treatment overall disability score (INCAT-ODSS). Results: A total of 48 of 181 patients (26.5%) received therapy with CYP, RTX, or BTZ. The most frequently and first used therapy was CYP (69%). More than 40% of patients needed a second or third treatment. Overall, 71 treatments were applied in 48 patients. The combination of up to all three treatments enhanced the response-rate to 90%. Treatment within 24 months after initial diagnosis resulted in significantly higher response rate than late treatment (79% versus 50 %, p = 0.04, χ2-test, n = 46) and in lower disability in long-term follow up (INCAT-ODSS 3.8 versus 5.8, p = 0.02, t-test, n = 48). Patients with Lewis-Sumner syndrome (n = 9) and autoantibody mediated neuropathies (n = 13) had excellent response rates after treatment with RTX (90–100%). In contrast, typical chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) showed a response rate of 64% in CYP, 64% in RTX, and 75% in BTZ. Conclusion: Treatment with CYP, RTX, or BTZ was effective in this cohort of CIN refractory to first-line treatment. Our data increase evidence for an early use of these therapies. High efficacy of RTX in Lewis-Sumner syndrome in contrast to typical CIDP suggests a distinct pathophysiology.
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Affiliation(s)
- Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, Bochum, 44791, Germany
| | - Anna Lena Fisse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Nuray Köse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Hannah Mork
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | | | - Miriam Fels
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Susanne Otto
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Ines Siglienti
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | | | - Kerstin Hellwig
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Min-Suk Yoon
- Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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Fisse AL, Motte J, Grüter T, Sgodzai M, Pitarokoili K, Gold R. Comprehensive approaches for diagnosis, monitoring and treatment of chronic inflammatory demyelinating polyneuropathy. Neurol Res Pract 2020; 2:42. [PMID: 33324942 PMCID: PMC7722337 DOI: 10.1186/s42466-020-00088-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/04/2020] [Indexed: 02/08/2023] Open
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is the most common chronic inflammatory neuropathy. CIDP is diagnosed according to the European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria, which combine clinical features with the electrophysiological evidence of demyelination. However, firstly, diagnosis is challenging, as some patients e.g. with severe early axonal damage do not fulfil the criteria. Secondly, objective and reliable tools to monitor the disease course are lacking. Thirdly, about 25% of CIDP patients do not respond to evidence-based first-line therapy. Recognition of these patients is difficult and treatment beyond first-line therapy is based on observational studies and case series only. Individualized immunomodulatory treatment does not exist due to the lack of understanding of essential aspects of the underlying pathophysiology. Novel diagnostic imaging techniques and molecular approaches can help to solve these problems but do not find enough implementation. This review gives a comprehensive overview of novel diagnostic techniques and monitoring approaches for CIDP and how these can lead to individualized treatment and better understanding of pathophysiology.
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Affiliation(s)
- Anna Lena Fisse
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Jeremias Motte
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Melissa Sgodzai
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.,Immunmediated Neuropathies Biobank (INHIBIT), Ruhr-University Bochum, Bochum, Germany
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3
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Distal Acquired Demyelinating Symmetric Neuropathy. Neuromuscul Disord 2018. [DOI: 10.1007/978-981-10-5361-0_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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4
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Martinez AR, Faber I, Nucci A, Appenzeller S, França MC. Autoimmune neuropathies associated to rheumatic diseases. Autoimmun Rev 2017; 16:335-342. [DOI: 10.1016/j.autrev.2017.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/06/2016] [Indexed: 12/11/2022]
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5
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D'Sa S, Kersten MJ, Castillo JJ, Dimopoulos M, Kastritis E, Laane E, Leblond V, Merlini G, Treon SP, Vos JM, Lunn MP. Investigation and management of IgM and Waldenström-associated peripheral neuropathies: recommendations from the IWWM-8 consensus panel. Br J Haematol 2017; 176:728-742. [PMID: 28198999 DOI: 10.1111/bjh.14492] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Paraproteinaemic neuropathies are a heterogeneous group of disorders most frequently associated with IgM monoclonal gammopathies including Waldenström macroglobulinaemia (WM). Their consequences are significant for affected patients, and their management challenging for their physicians. The variability in clinical presentation and time course hamper classification and management. The indications for invasive investigations such as cerebrospinal fluid analysis, nerve conduction tests and sensory nerve biopsies are unclear, and the optimum way to measure clinical response to treatment unknown. When to intervene and and how to treat, also present challenges to physicians. As part of its latest deliberations at the International Workshops on WM (IWWM) in London, UK (August 2014), the IWWM8 panel have proposed a consensus approach to the diagnosis and management of peripheral neuropathies associated with IgM monoclonal gammopathies, including WM. Importantly, a consensus regarding the use of clinical outcome measures and recommended models of care for this group of patients is discussed, as well as appropriate treatment interventions.
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Affiliation(s)
- Shirley D'Sa
- Waldenström Clinic, Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Marie José Kersten
- Department of Haematology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Meletios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Edward Laane
- Department of Haematology, North Estonia Medical Centre, Tallinn, Estonia
| | - Véronique Leblond
- AP-HP Hôpital Pitié Salpêtrière, UPMC Univ. Paris 6 GRC-11, Grechy, Paris, France
| | - Giampaolo Merlini
- Centre for Research and Treatment of Systemic Amyloidosis, University of Pavia, Pavia, Italy
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Josephine M Vos
- Department of Haematology, Academic Medical Centre, Amsterdam, the Netherlands.,Cancer Centre, Sint Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | - Michael P Lunn
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
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Mitsuma S, Van den Bergh P, Rajabally YA, Van Parijs V, Martin-Lamb D, Sonoo M, Inaba A, Shimizu T, Isose S, Sato Y, Komori T, Misawa S, Kuwabara S. Effects of low frequency filtering on distal compound muscle action potential duration for diagnosis of CIDP: A Japanese–European multicenter prospective study. Clin Neurophysiol 2015; 126:1805-10. [DOI: 10.1016/j.clinph.2014.11.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 10/30/2014] [Accepted: 11/15/2014] [Indexed: 12/14/2022]
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7
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Talamo G, Mir MA, Pandey MK, Sivik JK, Raheja D. IgM MGUS associated with anti-MAG neuropathy: a single institution experience. Ann Hematol 2015; 94:1011-6. [DOI: 10.1007/s00277-014-2294-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 12/23/2014] [Indexed: 11/24/2022]
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8
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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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11
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Missaoui B, Thoumie P. Balance training in ataxic neuropathies. Effects on balance and gait parameters. Gait Posture 2013; 38:471-6. [PMID: 23465318 DOI: 10.1016/j.gaitpost.2013.01.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 01/14/2013] [Accepted: 01/19/2013] [Indexed: 02/02/2023]
Abstract
A rehabilitation program including foot sensory stimulation, balance and gait training with limited vision was followed by 30 patients with ataxic neuropathy in order to stimulate multi-sensory compensation in a no-controlled and no-blinded study. Ataxic neuropathy was graded by a pallesthetic score. The evaluation of patients and healthy subjects was performed with clinical tests (Berg Balance Scale, Functional Reach Test and Timed up and Go test) and instrumental tests for balance (force platform) and gait (Locometre). All patients exhibited impairments in balance and gait parameters compared to control group values. A high pallesthetic score correlated with increased sway area when standing with the eyes open on a firm surface. At the end of the training program, significant changes were observed in balance control assessed using the three clinical tests (Wilcoxon test, p<0.001). A tendency towards a reduction of the Romberg sign was noticed and limited changes were observed after training in instrumental tests for balance and for gait parameters. Age induced some limitations in balance and gait parameters but had no effect on training results. These results show that ataxic patients are impaired in balance and gait but can improve clinical balance parameters following training with a multisensory approach without limitation due to age or degree of sensory impairment. Only limited correlations were noticed between the pallesthetic score and some balance parameters, suggesting that various levels of compensation occur in these patients. The effectiveness of this training program has to be evaluated in the future in a controlled study to ascertain the contribution of the placebo effect in these data.
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Affiliation(s)
- Besma Missaoui
- APHP, Neuro-Rehabilitation Centre for Neuromuscular Disorders, Rothschild Hospital, F-75012 Paris, France
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12
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Buttmann M, Kaveri S, Hartung HP. Polyclonal immunoglobulin G for autoimmune demyelinating nervous system disorders. Trends Pharmacol Sci 2013; 34:445-57. [PMID: 23791035 DOI: 10.1016/j.tips.2013.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 05/08/2013] [Accepted: 05/22/2013] [Indexed: 12/13/2022]
Abstract
Demyelinating diseases with presumed autoimmune pathogenesis are characterised by direct or indirect immune-mediated damage to myelin sheaths, which normally surround nerve fibres to ensure proper electrical nerve conduction. Parenteral administration of polyclonal IgG purified from multi-donor human plasma pools may beneficially modulate these misguided immune reactions via several mechanisms that are outlined in this review. Convincing therapeutic evidence from controlled trials now exists for certain disorders of the peripheral nervous system, including Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, and multifocal motor neuropathy. In addition, there is evidence for potential therapeutic benefits of IgG in patients with chronic inflammatory demyelinating diseases of the central nervous system, including multiple sclerosis and neuromyelitis optica. This review introduces these disorders, briefly summarises the established treatment options, and discusses therapeutic evidence for the use of polyclonal immunoglobulins with a particular emphasis on recent clinical trials and meta-analyses.
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Affiliation(s)
- Mathias Buttmann
- Department of Neurology, University of Würzburg, Josef-Schneider-Str. 11, D-97080 Würzburg, Germany
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13
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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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14
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Crone C, Krarup C. Neurophysiological approach to disorders of peripheral nerve. HANDBOOK OF CLINICAL NEUROLOGY 2013; 115:81-114. [PMID: 23931776 DOI: 10.1016/b978-0-444-52902-2.00006-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Disorders of the peripheral nerve system (PNS) are heterogeneous and may involve motor fibers, sensory fibers, small myelinated and unmyelinated fibers and autonomic nerve fibers, with variable anatomical distribution (single nerves, several different nerves, symmetrical affection of all nerves, plexus, or root lesions). Furthermore pathological processes may result in either demyelination, axonal degeneration or both. In order to reach an exact diagnosis of any neuropathy electrophysiological studies are crucial to obtain information about these variables. Conventional electrophysiological methods including nerve conduction studies and electromyography used in the study of patients suspected of having a neuropathy and the significance of the findings are discussed in detail and more novel and experimental methods are mentioned. Diagnostic considerations are based on a flow chart classifying neuropathies into eight categories based on mode of onset, distribution, and electrophysiological findings, and the electrophysiological characteristics in each type of neuropathy are discussed.
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Affiliation(s)
- Clarissa Crone
- Department of Clinical Neurophysiology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
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Abstract
Peripheral neuropathy associated with monoclonal gammopathy is a rare but important cause of neuropathy that can herald serious underlying disease. IgM monoclonal gammopathy of undetermined significance (MGUS) is the most commonly found monoclonal gammopathy associated with neuropathy, with characteristic clinical, electrophysiologic, and pathologic features. The IgG and IgA monoclonal gammopathies are rarely associated with specific neuropathies. Standard immunomodulatory agents including steroids, intravenous immunoglobulin, and plasmapheresis have shown limited efficacy in IgM MGUS. Neuropathies associated with specific lymphoproliferative disorders may not respond to treatments aimed at that disorder. Case series had shown promising results with rituximab, a monoclonal antibody that targets the B cell surface antigen CD20 and results in a rapid and sustained depletion of B cells; however, two recent randomized controlled trials with rituximab failed to provide evidence of efficacy in primary outcome measures, despite reduction in antibody levels. Long-term studies looking at the association between specific immunologic markers and disease recurrence are needed to ultimately develop targeted therapies.
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Affiliation(s)
- Sindhu Ramchandren
- Department of Neurology, Wayne State University-Detroit Medical Center, 4201 St. Antoine UHC 8C.28, Detroit, MI 48201, USA.
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Hutton EJ, Carty L, Laurá M, Houlden H, Lunn MPT, Brandner S, Mirsky R, Jessen K, Reilly MM. c-Jun expression in human neuropathies: a pilot study. J Peripher Nerv Syst 2012; 16:295-303. [PMID: 22176144 DOI: 10.1111/j.1529-8027.2011.00360.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Schwann cell dedifferentiation following nerve injury is important to permit neural survival and axonal regrowth. Animal studies have shown that the transcription factor c-Jun is upregulated in Schwann cells of injured and pathological nerves where it acts as an important regulator of Schwann cell plasticity, promoting dedifferentiation and demyelination. This pilot immunohistochemical study investigates whether c-Jun is also upregulated in human neuropathies. We examined c-Jun expression in normal and diseased human nerves, as well as in dermal myelinated nerve fibres. Our findings show that although as predicted c-Jun is rarely expressed in normal nerves, it is expressed in Schwann cell nuclei of pathological nerves as predicted by animal studies. Pathological dermal myelinated nerve fibres also show clear nuclear c-Jun expression. Further studies of c-Jun expression will help clarify its role in human neuropathies.
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Affiliation(s)
- Elspeth J Hutton
- MRC Centre for Neuromuscular Diseases, Department of Molecular Neurosciences, UCL Institute of Neurology, London, UK.
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Gruson B, Ghomari K, Beaumont M, Garidi R, Just A, Merle P, Merlusca L, Marolleau JP, Royer B. Long-term response to rituximab and fludarabine combination in IgM anti-myelin-associated glycoprotein neuropathy. J Peripher Nerv Syst 2011; 16:180-5. [DOI: 10.1111/j.1529-8027.2011.00343.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Advances in the treatment of chronic inflammatory demyelinating neuropathies in 2010. J Neurol 2011; 258:1737-41. [DOI: 10.1007/s00415-011-6143-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 06/06/2011] [Accepted: 06/08/2011] [Indexed: 11/25/2022]
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Bromberg MB. Review of the evolution of electrodiagnostic criteria for chronic inflammatory demyelinating polyradicoloneuropathy. Muscle Nerve 2011; 43:780-94. [DOI: 10.1002/mus.22038] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Adams D, Lozeron P, Théaudin M, Adam C, Lacroix C. Neuropatie periferiche nel corso delle disglobulinemie. Neurologia 2011. [DOI: 10.1016/s1634-7072(11)70699-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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21
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European Federation of Neurological Societies/Peripheral Nerve Society Guideline* on management of paraproteinemic demyelinating neuropathies. Report of a Joint Task Force of the European Federation of Neurological Societies and the Peripheral Nerve Socie. J Peripher Nerv Syst 2010; 15:185-95. [DOI: 10.1111/j.1529-8027.2010.00278.x] [Citation(s) in RCA: 189] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Hummel HD, Rath JC, Wiendl H, Hetzel W, Bargou RC, Toyka KV, Sommer C, Einsele H, Topp MS. Auto-SCT in severe paraproteinemic neuropathy. Bone Marrow Transplant 2010; 46:457-9. [PMID: 20577220 DOI: 10.1038/bmt.2010.124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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23
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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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Lehmann HC, Hoffmann FR, Meyer Zu Hörste G, Hartung HP, Kieseier BC. Central nervous system involvement in patients with monoclonal gammopathy and polyneuropathy. Eur J Neurol 2010; 17:1075-81. [PMID: 20236302 DOI: 10.1111/j.1468-1331.2010.02977.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate clinical presentation of patients with the clinical triad of monoclonal gammopathy, polyneuropathy and signs of CNS involvement. METHODS Nineteen patients with monoclonal protein (M-protein, 9 IgM, 10 IgG) were studied. Clinical examination, MRI, cerebrospinal fluid analysis and immune reactivity against myelin-associated glycoprotein and gangliosides in serum were obtained. By immunohistochemistry, different binding patterns of M-proteins to human CNS tissue were investigated. RESULTS Nine out of 19 patients (four IgM, five IgG) showed one or more clinical signs of CNS involvement. Clinical features associated with signs of CNS pathology were disease duration and greater concentration of IgM paraprotein. The IgM M-protein of two patients strongly stained the cortex/cerebellar neurons in human brain sections. CONCLUSION Our results complement previous reports that some patients with monoclonal gammopathy and polyneuropathy can develop solitary or disseminated signs of CNS involvement. It indicates that pathological effects of M-proteins are not necessarily restricted to the peripheral nervous system. The specificity and affinity of circulating M-protein to antigens in the CNS might be critical for the development of different clinical phenotypes.
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Affiliation(s)
- H C Lehmann
- Department of Neurology, Heinrich-Heine University, Düsseldorf, Germany.
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Magy L, Vallat JM. Evidence-Based Treatment Of Chronic Immune-Mediated Neuropathies. Expert Opin Pharmacother 2009; 10:1741-54. [DOI: 10.1517/14656560903036095] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Argyriou AA. Molecularly targeted therapies for dysimmune neuropathies. Mol Med 2009; 15:283-7. [PMID: 19593413 PMCID: PMC2707512 DOI: 10.2119/molmed.2009.00041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 05/04/2009] [Indexed: 01/27/2023] Open
Abstract
Conventional treatment options, including corticosteroids, intravenous immunoglobulin, or plasma exchange, often fail to treat dysimmune neuropathies, such as chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and monoclonal gammopathy with its subtypes. Therefore, a significant percentage of patients require adjunctive immunosuppressive therapies. Considering that even immunosuppressive agents often are ineffective and/or associated with significant toxicities, the need for the development of safe and effective new treatment options is rising. Currently, several monoclonal antibodies (MAbs) have been tested in open-label small-sized studies or even in single cases so as to establish future directions in the therapy of diseases of the peripheral nervous system (PNS). Rituximab, an MAb targeting against the B cell surface membrane protein CD20, is the most widely used and promising MAb for the treatment of dysimmune neuropathies, especially for those in which immunoglobulin M (IgM) autoantibodies are pathogenetically involved. The efficacy of alemtuzumab, bevacizumab, and etanercept to treat various forms of dysimmune neuropathies is currently under investigation. This review looks critically at recent developments in molecularly targeted therapies for dysimmune neuropathies and also highlights areas of future research to pursue.
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Affiliation(s)
- Andreas A Argyriou
- Department of Neurology, Saint Andrew's State General Hospital of Patras, Greece.
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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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Nobile-Orazio E. Antigenic Determinants in IgM Paraprotein-Related Neuropathies. ACTA ACUST UNITED AC 2009; 9:107-9. [DOI: 10.3816/clm.2009.n.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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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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Weinstein R. Therapeutic apheresis in neurological disorders: A survey of the evidence in support of current category I and II indications for therapeutic plasma exchange. J Clin Apher 2008; 23:196-201. [DOI: 10.1002/jca.20178] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
PURPOSE OF REVIEW To provide clinically useful guidelines in the management of neuropathy associated with monoclonal gammopathy from a review of the most recent literature and our own experience. RECENT FINDINGS Recent data on neuropathy associated with monoclonal gammopathy come from better descriptions of subgroups, and from new treatment compounds that have shown encouraging results in different entities. SUMMARY Neuropathies associated with monoclonal gammopathy are relatively rare and most often the neuropathy reveals the monoclonal gammopathy. These conditions require combined neurological and haematological assessments. Their clinical presentations are highly heterogeneous but most have an electrophysiological demyelinating pattern. The main described subgroup is IgM anti-(myelin-associated glycoprotein) neuropathy, which presents as a relatively benign, slowly progressive sensory neuropathy. Nerve biopsy should be considered in patients with progressive and disabling axonal neuropathy. Neuropathies associated with monoclonal gammopathy have various neurological and general outcomes, including life-threatening entities such as light-chain amyloid neuropathy and POEMS syndrome. Treatment choice is wide and depends both on the underlying haematological disorder and severity of the neuropathy. Intravenous immunoglobulin should be assessed in demyelinating monoclonal gammopathy of undetermined significance neuropathy. Malignant haematological disorders should be treated per se. The possibility of a malignant evolution of monoclonal gammopathy of undetermined significance warrants regular haematological monitoring.
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Affiliation(s)
- Pierre Lozeron
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Paris, France.
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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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Uzenot D, Azulay JP, Pouget J. Initier le traitement de la PRNC. Rev Neurol (Paris) 2007. [DOI: 10.1016/s0035-3787(07)92163-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Rossi D, Franceschetti S, Cerri M, Conconi A, Lunghi M, Capello D, Cantello R, Gaidano G. Hairy cell leukaemia complicated by anti-MAG paraproteinemic demyelinating neuropathy: resolution of neurological syndrome after cladribrine treatment. Leuk Res 2007; 31:873-6. [PMID: 17007925 DOI: 10.1016/j.leukres.2006.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Revised: 08/25/2006] [Accepted: 08/26/2006] [Indexed: 11/21/2022]
Abstract
Hairy cell leukaemia (HCL) occasionally displays a monoclonal gammopathy, yet the association of HCL with paraproteinemic demyelinating neuropathy (PDN) has not been reported. We describe a HCL case complicated by PDN and high titers of monoclonal IgM against myelin associated glycoprotein (MAG). Heavy and light chains of the patient's anti-MAG monoclonal protein were consistent with those expressed by HCL cells. After treatment with cladribrine, remission of HCL strictly paralleled disappearance of the IgM monoclonal protein and of the serum anti-MAG activity, and led to PDN clinical and electrophysiological improvement. Purine analogs may represent a choice in IgM PDN associated with lymphoproliferative disorders.
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Affiliation(s)
- Davide Rossi
- Division of Haematology, Department of Clinical and Experimental Medicine & IRCAD, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy.
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Abstract
The detection of a monoclonal immunoglobulin in serum or urine usually raises concerns about the size of the underlying B-cell-derived clone and possible systemic effects caused by its expansion. However, a small clone can synthesize a very toxic protein, producing devastating systemic damage and protean clinical presentations. The resulting "monoclonal component-related diseases," although difficult to diagnose, may be progressive and even fatal. The monoclonal protein can aggregate and deposit systemically as occurs in light-chain amyloidosis, monoclonal immunoglobulin deposition disease, crystal-storing histiocytosis, and monoclonal cryoglobulinemia. Alternatively, some monoclonal proteins possess antibody activity toward autogenous antigens and cause chronic cold agglutinin disease, mixed cryoglobulinemia, and peripheral neuropathies. Other humoral mediators may contribute to neuropathy in variant disorders such as the POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes) syndrome. The clone synthesizing the noxious monoclonal proteins is often small, and sensitive techniques may be required to detect these immunoglobulins. A delay in diagnosis can allow irreversible organ damage and dramatically shorten survival. Prompt recognition of suggestive signs and symptoms should trigger a thorough diagnostic approach to reach the correct diagnosis quickly, because this is the key to effective therapy. Although the treatment of these conditions is not optimal, significant advances have been made, improving the duration and quality of life.
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Affiliation(s)
- Giampaolo Merlini
- Amyloid Center, Biotechnology Research Laboratories, Foundation IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100 Pavia, Italy.
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