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Kapoor M, Reddel SW. Ways to think about vasculitic neuropathy. Curr Opin Neurol 2024; 37:478-486. [PMID: 39046107 DOI: 10.1097/wco.0000000000001301] [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: 07/25/2024]
Abstract
PURPOSE OF REVIEW Vasculitis as a pathomechanism for neuropathy can be isolated to the peripheral nervous system, a part of a systemic autoimmune condition or a component of another syndrome. This review aims to discuss the broad range of diagnoses in which vasculitic neuropathy can be encountered, highlight the progress in imaging techniques in identifying vasculitis, and the new drugs developed for other autoimmune diseases that may be applied to neurological conditions. RECENT FINDINGS Advances in imaging modalities, ultrasound, MRI and FDG-PET scanning for neuromuscular applications has redefined many aspects of vasculitic neuropathies. The benefit of dividing vasculitides by vessel size is becoming less absolute as diagnostic approaches advance. MRI and FDG-PET are widely used in diagnosis, defining extent of involvement of disease and monitoring. In neuralgic amyotrophy, the identification of hourglass-like constrictions on imaging has changed the treatment paradigm to include surgical interventions. These diagnostic approaches are supported by new immunomodulating and immunosuppression techniques. SUMMARY Vasculitic neuropathies are a broad group of conditions with a range of causes and associations. Increased use of imaging techniques impacts our traditional definitions and classifications. The growth in treatment options for other autoimmune conditions are likely to infiltrate the neurological landscape.
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Affiliation(s)
- Mahima Kapoor
- Department of Neurosciences, Central Clinical School, Monash University, Alfred Centre, Melbourne, Victoria
| | - Stephen W Reddel
- ANZAC Research Institute, Central Clinical School, University of Sydney, Sydney, Australia
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2
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Kohle F, Wunderlich G, Fink GR, Schroeter M, Lehmann HC, Schneider C. Rituximab in non-systemic vasculitic neuropathy: a single-center experience. J Neurol 2024; 271:4406-4411. [PMID: 38656623 PMCID: PMC11233319 DOI: 10.1007/s00415-024-12378-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVES This case series reports clinical features and outcome of four patients with non-systemic vasculitic neuropathy (NSVN) treated with the anti-CD20 agent rituximab. METHODS Clinical, electrophysiological and biopsy data were retrospectively obtained and evaluated. Only patients with pathological definite or probable NSVN were included. Extensive clinical and laboratory work-up excluded systemic vasculitis. Follow-up data for at least 12 months and up to five years is provided. Outcome of the patients was assessed using the MRC-Sum Score, Prineas Score and Neurological Symptom Score. RESULTS Two of four patients treated with rituximab achieved disease remission and one patient remained stable under anti-CD20 therapy after a required treatment switch due to toxic side effects of cyclophosphamide. One patient deteriorated under rituximab induction. Rituximab was well tolerated in all patients. DISCUSSION Anti-CD20 therapy might be an alternative in NSVN patients requiring further treatment escalation or treatment switch due to side effects of corticosteroids or cyclophosphamide.
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Affiliation(s)
- Felix Kohle
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany.
| | - Gilbert Wunderlich
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany
- Center for Rare Diseases, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Gereon R Fink
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany
- Cognitive Neuroscience, Research Center Juelich, Institute of Neuroscience and Medicine (INM-3), Juelich, Germany
| | - Michael Schroeter
- Department of Neurology, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany
| | - Helmar C Lehmann
- Department of Neurology, Hospital Leverkusen, Leverkusen, Germany
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3
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Baima JPS, Silva BCG, Vieira VL, Meireles LP, Arai MH, Lino AMM. A great simulator in clinical practice: mononeuritis multiplex in HIV infection. Autops Case Rep 2024; 14:e2024493. [PMID: 39021464 PMCID: PMC11253905 DOI: 10.4322/acr.2024.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 04/21/2024] [Indexed: 07/20/2024]
Abstract
HIV infection is a chameleon, mimicking several diseases. Herein, we report a previously healthy 39-year-old woman who, over 2 months, developed arthritis, weight loss, and confluent multiple mononeuropathy. Extensive laboratory investigation showed positive serology for HIV, with a CD4 count of 100 cells, and necrotizing vasculitis on a nerve biopsy not associated with CMV co-infection, allowing the diagnosis of polyarteritis nodosa-like vasculitis in an HIV-infected patient. Apart from the infection, HIV-related autoimmunity can affect any organ and contribute to the complexity of the clinical presentation of HIV infection.
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Affiliation(s)
- José Pedro Soares Baima
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo, SP, Brasil
| | - Beatriz Carneiro Gondim Silva
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo, SP, Brasil
| | - Vanessa Lopes Vieira
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Medicina Interna, São Paulo, SP, Brasil
| | - Luiz Pedro Meireles
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Medicina Interna, São Paulo, SP, Brasil
| | - Milton Hideaki Arai
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Medicina Interna, São Paulo, SP, Brasil
| | - Angelina Maria Martins Lino
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo, SP, Brasil
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Mohamed AA, Caussat T, Mouhawasse E, Ali R, Johansen PM, Lucke-Wold B. Neurosurgical Intervention for Nerve and Muscle Biopsies. Diagnostics (Basel) 2024; 14:1169. [PMID: 38893695 PMCID: PMC11172125 DOI: 10.3390/diagnostics14111169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/21/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
(1) Background: Neurologic and musculoskeletal diseases represent a considerable portion of the underlying etiologies responsible for the widely prevalent symptoms of pain, weakness, numbness, and paresthesia. Because of the subjective and often nonspecific nature of these symptoms, different diagnostic modalities have been explored and utilized. (2) Methods: Literature review. (3) Results: Nerve and muscle biopsy remains the gold standard for diagnosing many of the responsible neurological and musculoskeletal conditions. However, the need for invasive tissue sampling is diminishing as more investigations explore alternative diagnostic modalities. Because of this, it is important to explore the current role of neurosurgical intervention for nerve and muscle biopsies and its current relevance in the diagnostic landscape of neurological and musculoskeletal disorders. With consideration of the role of nerve and muscle biopsy, it is also important to explore innovations and emerging techniques for conducting these procedures. This review explores the indications and emerging techniques for neurological intervention for nerve and muscle biopsies. (4) Conclusions: The role of neurosurgical intervention for nerve and muscle biopsy remains relevant in diagnosing many neurological and musculoskeletal disorders. Biopsy is especially relevant as a supportive point of evidence for diagnosis in atypical cases. Additionally, emerging techniques have been explored to guide diagnostics and biopsy, conduct less invasive biopsies, and reduce risks of worsening neurologic function and other symptoms secondary to biopsy.
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Affiliation(s)
- Ali A. Mohamed
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Thomas Caussat
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Edwin Mouhawasse
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Rifa Ali
- College of Medicine, University of Central Florida, Orlando, FL 32827, USA
| | - Phillip M. Johansen
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33613, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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5
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Younger DS. Headaches and Vasculitis. Neurol Clin 2024; 42:389-432. [PMID: 38575258 DOI: 10.1016/j.ncl.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability making this a disorder of paramount importance to all clinicians. Headache may be an important clue to vasculitic involvement of central nervous system (CNS) vessels. CNS vasculitis may be primary, in which only intracranial vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. Primary neurologic vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible.
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Affiliation(s)
- David S Younger
- Department of Medicine, Section of Neuroscience, City University of New York School of Medicine, New York, NY, USA; Department of Neurology, White Plains Hospital, White Plains, NY, USA.
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Songtanin B, Chaisrimaneepan N, Mendóza R, Nugent K. Burden, Outcome, and Comorbidities of Extrahepatic Manifestations in Hepatitis B Virus Infections. Viruses 2024; 16:618. [PMID: 38675959 PMCID: PMC11055091 DOI: 10.3390/v16040618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/11/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Hepatitis B virus (HBV) infections affect approximately 296 million people around the world, and the prevalence of any past or present HBV infection during the years 2015-2018 was as high as 4.3%. Acute HBV infection often presents with nonspecific symptoms and is usually self-limited, but 5% of patients can have persistent infections leading to chronic HBV infection and the risk of turning into chronic HBV infection is significantly higher in babies with vertical transmission (95%). Patients with chronic HBV infection are usually asymptomatic, but 15 to 40% of chronic HBV carriers develop cirrhosis and/or hepatocellular carcinoma. In addition to liver-related disorders, HBV is also associated with several extrahepatic complications, including glomerulonephritis, cryoglobulinemia, neurologic disorders, psychological manifestations, polyarthritis, and dermatologic disorders. Making the diagnosis of HBV can be challenging since patients with chronic infections can remain symptom-free for decades before developing cirrhosis or hepatocellular carcinoma, and patients with acute HBV infection may have only mild, nonspecific symptoms. Therefore, understanding how this virus causes extrahepatic complications can help clinicians consider this possibility in patients with diverse symptom presentations. The pathophysiology of these extrahepatic disorders likely involves immune-related tissue injury following immune complex formation and inflammatory cascades. In some cases, direct viral infection of extrahepatic tissue may cause a clinical syndrome. Currently, the American Association for the Study of Liver Diseases recommends treatment of chronic HBV infections with interferon therapy and/or nucleos(t)ide analogs, and this treatment has been reported to improve some extrahepatic disorders in some patients with chronic HBV infection. These extrahepatic complications have a significant role in disease outcomes and increase medical costs, morbidity, and mortality. Therefore, understanding the frequency and pathogenesis of these extrahepatic complications provides important information for both specialists and nonspecialists and may help clinicians identify patients at an earlier stage of their infection.
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Affiliation(s)
- Busara Songtanin
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA (K.N.)
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Wang S, A. A, Feinstein D, Traisak P, Eid H, Karpoff M. An Unusual Case of Peripheral Nerve Vasculitis. Case Rep Rheumatol 2024; 2024:3469182. [PMID: 38317741 PMCID: PMC10843867 DOI: 10.1155/2024/3469182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/08/2023] [Accepted: 01/16/2024] [Indexed: 02/07/2024] Open
Abstract
Peripheral neuropathy is a common manifestation of systemic vasculitis. The etiology of vasculitic peripheral neuropathy is generally classified into two groups: systemic and nonsystemic. In systemic vasculitic neuropathy (SVN), neuropathy is a consequence of a systemic disease, most commonly involving medium and small vessels throughout the body. There are three main clinical presentations: multifocal neuropathy, distal symmetric polyneuropathy, and overlapping multifocal neuropathy. Specifically, distal symmetric polyneuropathy affects multiple somatic nerves diffusely in a symmetric and length-dependent pattern (also known as the classic stocking-glove pattern). This case represents an atypical presentation of SVN, presenting with widespread symmetric polyneuropathy.A 73-year-old woman presented with distal acute on chronic bilateral upper and lower extremity weakness, sensory changes, and widespread pain. Symptoms started about three months prior and gradually worsened with progressive difficulty with ambulation and required assistive devices. Elevated ESR is at 70 mm/hour, CRP at 25.66 mg/dL, elevated c-ANCA titers at 1 : 320 and PR3 at 5.0 AI, and elevated creatine kinase (CK) at 500-600 U/L. A muscle biopsy of the left vastus showed neurogenic atrophy without myositis. Initial improvement was with oral prednisone, but was stopped on discharge. Many purpuric and petechial lesions were developed on distal legs/feet and right fourth digit distal gangrene. EMG showed distal, symmetric, and axonal polyneuropathy affecting the upper and lower extremities and acute denervation in more distal muscles. The patient received pulse dose steroids and two doses of rituximab induction therapy and was discharged with an oral steroid taper. The patient's symptoms started as distal symmetric neuropathy at the onset and progressively worsened over the course of 3 months. Neuropathy, both on the exam and on EMG, seemed to have developed more rapidly than expected, regardless of its distribution. The EMG showed severe peripheral nerve damage and denervation, which is unusual for ANCA-associated systemic vasculitis.
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Affiliation(s)
- S. Wang
- Cooper University Health Care, Camden, NJ, USA
| | - Arsany A.
- Care Point Health, Jersey City, NJ, USA
| | - D. Feinstein
- Cooper University Health Care, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - P. Traisak
- Cooper University Health Care, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - H. Eid
- Cooper University Health Care, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - M. Karpoff
- Cooper University Health Care, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
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Farina A, Escalere M, Dion M, Moussy M, Pegat A, Villagrán-García M, Devic P, Lamiral A, Seyve A, Aure K, Wang A, Gorza L, Streichenberger N, Maisonobe T, Honnorat J, Birzu C, Psimaras D, Weisenburger-Lile D, Joubert B. Mononeuritis multiplex following immune checkpoint inhibitors in malignant pleural mesothelioma. Front Neurol 2024; 15:1338899. [PMID: 38333608 PMCID: PMC10850347 DOI: 10.3389/fneur.2024.1338899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
Introduction Mononeuritis multiplex is frequently related to vasculitic neuropathy and has been reported only sporadically as an adverse event of immune checkpoint inhibitors. Methods Case series of three patients with mononeuritis multiplex-all with mesothelioma-identified in the databases of two French clinical networks (French Reference Center for Paraneoplastic Neurological Syndromes, Lyon; OncoNeuroTox, Paris; January 2015-October 2022) set up to collect and investigate n-irAEs on a nationwide level. Results Three patients (male; median age 86 years; range 72-88 years) had pleural mesothelioma and received 10, 4, and 6 cycles, respectively, of first-line nivolumab plus ipilimumab combined therapy. In patient 1, the neurological symptoms involved the median nerves, and in the other two patients, there was a more diffuse distribution; the symptoms were severe (common terminology criteria for adverse events, CTCAE grade 3) in all patients. Nerve conduction studies indicated mononeuritis multiplex in all patients. Peripheral nerve biopsy demonstrated necrotizing vasculitis in patients 1 and 3 and marked IgA deposition without inflammatory lesions in patient 2. Immune checkpoint inhibitors were permanently withdrawn, and corticosteroids were administered to all patients, leading to complete symptom regression (CTCAE grade 0, patient 2) or partial improvement (CTCAE grade 2, patients 1 and 3). During steroid tapering, patient 1 experienced symptom recurrence and spreading to other nerve territories (CTCAE grade 3); he improved 3 months after rituximab and cyclophosphamide administration. Discussion We report the occurrence of mononeuritis multiplex, a very rare adverse event of immune checkpoint inhibitors, in the three patients with mesothelioma. Clinicians must be aware of this severe, yet treatable adverse event.
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Affiliation(s)
- Antonio Farina
- Centre de Référence Français des Syndromes Neurologiques Paranéoplasiques et des Encéphalites Auto-immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS—UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Manon Escalere
- Unité de Neurologie et de Neurovasculaire, Foch Hospital, Suresnes, France
| | - Matthias Dion
- Centre de Référence Français des Syndromes Neurologiques Paranéoplasiques et des Encéphalites Auto-immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
| | - Martin Moussy
- Service de Neurologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Antoine Pegat
- Service ENMG et Pathologies Neuromusculaires, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Macarena Villagrán-García
- Centre de Référence Français des Syndromes Neurologiques Paranéoplasiques et des Encéphalites Auto-immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS—UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Perrine Devic
- Service de Neurologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Anaïde Lamiral
- Service de Neurologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Antoine Seyve
- Service de Neuro-Oncologie, Hôpital Neurologique, Hospices Civils de Lyon, Lyon, France
| | - Karine Aure
- Unité de Neurologie et de Neurovasculaire, Foch Hospital, Suresnes, France
| | - Adrien Wang
- Unité de Neurologie et de Neurovasculaire, Foch Hospital, Suresnes, France
| | - Lucas Gorza
- Unité de Neurologie et de Neurovasculaire, Foch Hospital, Suresnes, France
| | - Nathalie Streichenberger
- Service de Neuropathologie, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Institut NeuroMyogène, CNRS UMR 5261—INSERM U1315, Lyon, France
| | - Thierry Maisonobe
- Département de Neurophysiologie Clinique, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Jerome Honnorat
- Centre de Référence Français des Syndromes Neurologiques Paranéoplasiques et des Encéphalites Auto-immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS—UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
| | - Cristina Birzu
- Sorbonne Université, Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Paris, France
- INSERM, CNRS, Assistance Publique-Hôpitaux de Paris, Institut du Cerveau Et de La Moelle Épinière, Sorbonne Université, Paris, France
| | - Dimitri Psimaras
- Sorbonne Université, Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Paris, France
- INSERM, CNRS, Assistance Publique-Hôpitaux de Paris, Institut du Cerveau Et de La Moelle Épinière, Sorbonne Université, Paris, France
| | | | - Bastien Joubert
- Centre de Référence Français des Syndromes Neurologiques Paranéoplasiques et des Encéphalites Auto-immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- MeLiS—UCBL-CNRS UMR 5284—INSERM U1314, Université Claude Bernard Lyon 1, Lyon, France
- Service de Neurologie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
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Nakamura Y, Usami K, Taniguchi T, Nakajima S, Kaku Y, Takahashi R. [Mononeuropathy multiplex caused by cutaneous arteritis diagnosed by skin biopsies for emerging atypical erythema on upper limbs following neurological symptoms: a case report]. Rinsho Shinkeigaku 2024; 64:33-38. [PMID: 38092413 DOI: 10.5692/clinicalneurol.cn-001912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
A 33-year-old female was admitted to our department complaining of multifocal paresthesia and weakness of the upper and lower extremities that had developed over the previous three months. She had also been undergoing treatment for atopic dermatitis with dupilumab, an anti-interleukin 4/13 receptor antibody. A nerve conduction study revealed multifocal axonal sensorimotor neuropathy of bilateral limbs. On admission, a small erythema appeared on her right forearm, but it was atypical for vasculitic skin lesions due to its location and time course. Nonetheless, a biopsy revealed medium-sized vessel vasculitis. The patient was therefore diagnosed with vasculitic neuropathy caused by cutaneous arteritis. Methylprednisolone pulse therapy with prednisolone and azathioprine markedly improved her symptoms. A skin biopsy is useful when mononeuropathy multiplex is suspected, even if the skin findings are atypical for vasculitic rash.
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Affiliation(s)
- Yamato Nakamura
- Department of Neurology, Kyoto University Graduate School of Medicine
| | - Kiyohide Usami
- Department of Neurology, Kyoto University Graduate School of Medicine
- Department of Neurology, Japan Community Health Care Organization Yamato Koriyama Hospital
| | - Tomohiko Taniguchi
- Department of Neurology, Kyoto University Graduate School of Medicine
- Department of Neurology, Shizuoka General Hospital
| | | | - Yo Kaku
- Department of Dermatology, Kyoto University Hospital
| | - Ryosuke Takahashi
- Department of Neurology, Kyoto University Graduate School of Medicine
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Slouma M, Ben Dhia S, Cheour E, Gharsallah I. Acroparesthesias: An Overview. Curr Rheumatol Rev 2024; 20:115-126. [PMID: 37921132 DOI: 10.2174/0115733971254976230927113202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 08/09/2023] [Accepted: 08/18/2023] [Indexed: 11/04/2023]
Abstract
Acroparesthesia is a symptom characterized by a subjective sensation, such as numbness, tingling, prickling, and reduced sensation, affecting the extremities (fingers and toes). Despite its frequency, data regarding its diagnostic approach and management are scarce. The etiological diagnosis of acroparesthesia is sometimes challenging since it can be due to abnormality anywhere along the sensory pathway from the peripheral nervous system to the cerebral cortex. Acroparesthesia can reveal several diseases. It can be associated with rheumatic complaints such as arthritis or myalgia. Further cautions are required when paresthesia is acute (within days) in onset, rapidly progressive, severe, asymmetric, proximal, multifocal, or associated with predominant motor signs (limb weakness) or severe dysautonomia. Acroparesthesia may reveal Guillain-Barré syndrome or vasculitis, requiring rapid management. Acroparesthesia is a predominant symptom of polyneuropathy, typically distal and symmetric, often due to diabetes. However, it can occur in other diseases such as vitamin B12 deficiency, monoclonal gammopathy of undetermined significance, or Fabry's disease. Mononeuropathy, mainly carpal tunnel syndrome, remains the most common cause of acroparesthesia. Ultrasonography contributes to the diagnosis of nerve entrapment neuropathy by showing nerve enlargement, hypoechogenic nerve, and intraneural vascularity. Besides, it can reveal its cause, such as space-occupying lesions, anatomical nerve variations, or anomalous muscle. Ultrasonography is also helpful for entrapment neuropathy treatment, such as ultrasound-guided steroid injection or carpal tunnel release. The management of acroparesthesia depends on its causes. This article aimed to review and summarize current knowledge on acroparesthesia and its causes. We also propose an algorithm for the management of acroparesthesia.
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Affiliation(s)
- Maroua Slouma
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Siwar Ben Dhia
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Elhem Cheour
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
- Pain Treatment Center, La Rabta Hospital, Tunis, Tunisia
| | - Imen Gharsallah
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
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Kopanidis P, Baskozos G, Byrne E, Hofer M, Themistocleous AC, Rinaldi S, Bennett DL. Utilising clinical parameters to improve the selection of nerve biopsy candidates. Intern Med J 2023; 53:2224-2230. [PMID: 37186479 DOI: 10.1111/imj.16099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 03/31/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Peripheral nerve biopsy is a valuable final diagnostic tool; however, histopathological results can be non-diagnostic. AIMS We aim to identify quality improvement measures by evaluating the pre-biopsy assessment and diagnostic yield of specific histopathological diagnosis. METHODS This was a retrospective study based on 10 years of experience with peripheral nerve biopsies at a single centre. Clinical data were obtained regarding pre-biopsy history, examination, serum and cerebrospinal fluid (CSF) investigations, neurophysiology and peripheral nerve imaging. Based upon a histopathological outcome, patients were grouped into vasculitis, granulomatous and infiltrative (diagnostic) group, or a comparison group of non-specific axonal neuropathy and normal (non-specific/normal) group. RESULTS From a cohort of 64 patients, 21 (32.8%) were included in the diagnostic group and 30 (46.9%) in the non-specific/normal group. Clinical parameters associated with the diagnostic group were shorter history (mean 10.2 months vs 38.1), stepwise progression (81% vs 20%), neuropathic pain (85.7% vs 56.7%), vasculitic rash (23.8% vs 0%), mononeuritis multiplex (57.1% vs 10%), asymmetry (90.5% vs 60%), raised white cell count (47.6% vs 16.7%), myeloperoxidase antibody (19.1% vs 0%) and abnormal peripheral nerve imaging (33.3% vs 10%). CONCLUSION Selection of patients undergoing nerve biopsy requires careful consideration of clinical parameters, including peripheral nerve imaging. Several quality improvement measures are proposed to improve yield of clinically actionable information from nerve biopsy.
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Affiliation(s)
- Paul Kopanidis
- Department of Neurology, Northern Health, Melbourne, Victoria, Australia
- Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Georgios Baskozos
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Elizabeth Byrne
- Neuropathology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Monika Hofer
- Neuropathology Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Simon Rinaldi
- Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - David L Bennett
- Department of Neurology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Frontera JA, Guekht A, Allegri RF, Ashraf M, Baykan B, Crivelli L, Easton A, Garcia-Azorin D, Helbok R, Joshi J, Koehn J, Koralnik I, Netravathi M, Michael B, Nilo A, Özge A, Padda K, Pellitteri G, Prasad K, Romozzi M, Saylor D, Seed A, Thakur K, Uluduz D, Vogrig A, Welte TM, Westenberg E, Zhuravlev D, Zinchuk M, Winkler AS. Evaluation and treatment approaches for neurological post-acute sequelae of COVID-19: A consensus statement and scoping review from the global COVID-19 neuro research coalition. J Neurol Sci 2023; 454:120827. [PMID: 37856998 DOI: 10.1016/j.jns.2023.120827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/14/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
Post-acute neurological sequelae of COVID-19 affect millions of people worldwide, yet little data is available to guide treatment strategies for the most common symptoms. We conducted a scoping review of PubMed/Medline from 1/1/2020-4/1/2023 to identify studies addressing diagnosis and treatment of the most common post-acute neurological sequelae of COVID-19 including: cognitive impairment, sleep disorders, headache, dizziness/lightheadedness, fatigue, weakness, numbness/pain, anxiety, depression and post-traumatic stress disorder. Utilizing the available literature and international disease-specific society guidelines, we constructed symptom-based differential diagnoses, evaluation and management paradigms. This pragmatic, evidence-based consensus document may serve as a guide for a holistic approach to post-COVID neurological care and will complement future clinical trials by outlining best practices in the evaluation and treatment of post-acute neurological signs/symptoms.
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Affiliation(s)
- Jennifer A Frontera
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA.
| | - Alla Guekht
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
| | | | - Mariam Ashraf
- Department of Anesthesiology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Betül Baykan
- Department of Neurology, Istanbul University, Istanbul Faculty of Medicine, and EMAR Medical Center, Istanbul, Turkey
| | - Lucía Crivelli
- Department of Cognitive Neurology, Fleni, Buenos Aires, Argentina
| | - Ava Easton
- The Encephalitis Society, Malton, UK; Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - David Garcia-Azorin
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria; Department of Neurology, Johannes Kepler University, Linz, Austria
| | - Jatin Joshi
- Department of Anesthesiology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Julia Koehn
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Igor Koralnik
- Departmentof Neurology, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - M Netravathi
- Department of Neurology, National Institute of Mental Health & Neurosciences, Bangalore, India
| | - Benedict Michael
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, University of Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Annacarmen Nilo
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Aynur Özge
- Department of Neurology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Karanbir Padda
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Gaia Pellitteri
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Kameshwar Prasad
- Chief Executive Office, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Marina Romozzi
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Dipartimento Universitario Di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Deanna Saylor
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Adam Seed
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kiran Thakur
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Derya Uluduz
- Department of Neurology, Istanbul University, Istanbul Faculty of Medicine, and EMAR Medical Center, Istanbul, Turkey
| | - Alberto Vogrig
- Clinical Neurology, Santa Maria della Misericordia University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy; Department of Medicine, University of Udine Medical School, Udine, Italy
| | - Tamara M Welte
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany; Department of Neurology, Center for Global Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Erica Westenberg
- Department of Neurology, Center for Global Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dmitry Zhuravlev
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - Mikhail Zinchuk
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - Andrea S Winkler
- Department of Neurology, Center for Global Health, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway; Blavatnik Institute of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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13
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Collins MP, Hadden RDM, Shahnoor N. Primary perineuritis, a rare but treatable neuropathy: Review of perineurial anatomy, clinicopathological features, and differential diagnosis. Muscle Nerve 2023; 68:696-713. [PMID: 37602939 DOI: 10.1002/mus.27949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/10/2023] [Accepted: 07/16/2023] [Indexed: 08/22/2023]
Abstract
The perineurium surrounds each fascicle in peripheral nerves, forming part of the blood-nerve barrier. We describe its normal anatomy and function. "Perineuritis" refers to both a nonspecific histopathological finding and more specific clinicopathological entity, primary perineuritis (PP). Patients with PP are often assumed to have nonsystemic vasculitic neuropathy until nerve biopsy is performed. We systematically reviewed the literature on PP and developed a differential diagnosis for histopathologically defined perineuritis. We searched PubMed, Embase, Scopus, and Web of Science for "perineuritis." We identified 20 cases (11 M/9F) of PP: progressive, unexplained neuropathy with biopsy showing perineuritis without vasculitis or other known predisposing condition. Patients ranged in age from 18 to 75 (mean 53.7) y and had symptoms 2-24 (median 4.5) mo before diagnosis. Neuropathy was usually sensory-motor (15/20), painful (18/19), multifocal (16/20), and distal-predominant (16/17) with legs more affected than arms. Truncal numbness occurred in 6/17; 10/18 had elevated cerebrospinal fluid (CSF) protein. Electromyography (EMG) and nerve conduction studies (NCS) demonstrated primarily axonal changes. Nerve biopsies showed T-cell-predominant inflammation, widening, and fibrosis of perineurium; infiltrates in epineurium in 10/20 and endoneurium in 7/20; and non-uniform axonal degeneration. Six had epithelioid cells. 19/20 received corticosteroids, 8 with additional immunomodulators; 18/19 improved. Two patients did not respond to intravenous immunoglobulin (IVIg). At final follow-up, 13/16 patients had mild and 2/16 moderate disability; 1/16 died. Secondary causes of perineuritis include leprosy, vasculitis, neurosarcoidosis, neuroborreliosis, neurolymphomatosis, toxic oil syndrome, eosinophilia-myalgia syndrome, and rarer conditions. PP appears to be an immune-mediated, corticosteroid-responsive disorder. It mimics nonsystemic vasculitic neuropathy. Cases with epithelioid cells might represent peripheral nervous system (PNS)-restricted forms of sarcoidosis.
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Affiliation(s)
- Michael P Collins
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Nazima Shahnoor
- Neuromuscular Pathology Laboratory, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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14
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Tracy JA. Autoimmune Axonal Neuropathies. Continuum (Minneap Minn) 2023; 29:1378-1400. [PMID: 37851035 DOI: 10.1212/con.0000000000001344] [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: 10/19/2023]
Abstract
OBJECTIVE This article reviews autoimmune axonal neuropathies, their characteristic clinical features, disease and antibody associations, appropriate ancillary testing, treatment, and prognosis. LATEST DEVELOPMENTS In 2021, the American College of Rheumatology and the Vasculitis Foundation released new summary guidelines for the treatment of antineutrophil cytoplasmic autoantibody-associated vasculitides. In addition, novel autoantibodies have been recently identified; they are often paraneoplastic and associated with axonal neuropathies. ESSENTIAL POINTS Recognition of autoimmune axonal neuropathies is important because of the potential for effective treatment to either reverse deficits or slow the progression of disease. It is necessary to properly assess for associations with other systemic disorders (eg, systemic vasculitis, connective tissue disease, neoplasm) so that adequate treatment for both neurologic and non-neurologic aspects of the disease can be initiated.
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15
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Sim NK, Ismail A, Alam T, Shanmugarajah PD. Adalimumab-induced sensory vasculitic neuropathy. Drug Ther Bull 2023; 61:140-143. [PMID: 36649976 DOI: 10.1136/dtb.2022.246401.rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Nicholas Keyi Sim
- Department of Neurology, Calderdale and Huddersfield NHS Foundation Trust, Halifax, UK
| | - Azzam Ismail
- Department of Pathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Taimour Alam
- Department of Clinical Neurophysiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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16
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Foster MA, Lunn MP, Carr AS. First-line immunosuppression in neuromuscular diseases. Pract Neurol 2023:pn-2023-003708. [PMID: 37173131 DOI: 10.1136/pn-2023-003708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 05/15/2023]
Abstract
Autoimmune neuromuscular diseases are common and often treatable causes for peripheral nervous system dysfunction. If not optimally managed, they result in meaningful impairments and disability. The treating neurologist should aim to maximise clinical recovery with minimal iatrogenic risk. This requires careful patient and medication selection, appropriate counselling and close monitoring of clinical efficacy and safety. Here, we summarise our consensus departmental approach to first-line immunosuppression in neuromuscular diseases. We combine multispecialty evidence and expertise with a focus on autoimmune neuromuscular diseases to create guidance on starting, dosing and monitoring for toxic effects of the commonly used drugs. These include corticosteroids, steroid-sparing agents and cyclophosphamide. We also provide efficacy monitoring advice, as clinical response informs dosage and drug choice. The principles of this approach could be applied across much of the spectrum of immune-mediated neurological disorders where there is significant therapeutic crossover.
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Affiliation(s)
- Michael A Foster
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Division of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael Pt Lunn
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Aisling S Carr
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
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17
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Appeltshauser L, Linke J, Heil HS, Karus C, Schenk J, Hemmen K, Sommer C, Doppler K, Heinze KG. Super-resolution imaging pinpoints the periodic ultrastructure at the human node of Ranvier and its disruption in patients with polyneuropathy. Neurobiol Dis 2023; 182:106139. [PMID: 37146836 DOI: 10.1016/j.nbd.2023.106139] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/13/2023] [Accepted: 04/25/2023] [Indexed: 05/07/2023] Open
Abstract
The node of Ranvier is the key element in saltatory conduction along myelinated axons, but its specific protein organization remains elusive in the human species. To shed light on nanoscale anatomy of the human node of Ranvier in health and disease, we assessed human nerve biopsies of patients with polyneuropathy by super-resolution fluorescence microscopy. We applied direct stochastic optical reconstruction microscopy (dSTORM) and supported our data by high-content confocal imaging combined with deep learning-based analysis. As a result, we revealed a ~ 190 nm periodic protein arrangement of cytoskeletal proteins and axoglial cell adhesion molecules in human peripheral nerves. In patients with polyneuropathy, periodic distances increased at the paranodal region of the node of Ranvier, both at the axonal cytoskeleton and at the axoglial junction. In-depth image analysis revealed a partial loss of proteins of the axoglial complex (Caspr-1, neurofascin-155) in combination with detachment from the cytoskeletal anchor protein ß2-spectrin. High content analysis showed that such paranodal disorganization occurred especially in acute and severe axonal neuropathy with ongoing Wallerian degeneration and related cytoskeletal damage. We provide nanoscale and protein-specific evidence for the prominent, but vulnerable role of the node of Ranvier for axonal integrity. Furthermore, we show that super-resolution imaging can identify, quantify and map elongated periodic protein distances and protein interaction in histopathological tissue samples. We thus introduce a promising tool for further translational applications of super resolution microscopy.
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Affiliation(s)
| | - Janis Linke
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany; Rudolf Virchow Center, Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany
| | - Hannah S Heil
- Rudolf Virchow Center, Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany; Optical Cell Biology, Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Christine Karus
- Rudolf Virchow Center, Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany
| | - Joachim Schenk
- Rudolf Virchow Center, Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany
| | - Katherina Hemmen
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Claudia Sommer
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Kathrin Doppler
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany.
| | - Katrin G Heinze
- Rudolf Virchow Center, Center for Integrative and Translational Bioimaging, University of Würzburg, Würzburg, Germany.
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18
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Wu KY, Murthy NK, Howe BM, Dyck PJB, Spinner RJ. Diagnostic value of proximal cutaneous nerve biopsy in brachial and lumbosacral plexus pathologies. Acta Neurochir (Wien) 2023; 165:1189-1194. [PMID: 37009932 DOI: 10.1007/s00701-023-05565-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/16/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Brachial and lumbosacral plexopathies can result from numerous non-traumatic etiologies, including those of inflammatory, autoimmune, or neoplastic origin, that often require nerve biopsy for diagnosis. The purpose of this study was to evaluate the diagnostic efficacy of medial antebrachial cutaneous nerve (MABC) and posterior femoral cutaneous nerve (PFCN) nerve biopsies in proximal brachial and lumbosacral plexus pathology. METHOD Patients undergoing MABC or PFCN nerve biopsies at a single institution were reviewed. Patient demographics, clinical diagnosis, symptom duration, intraoperative findings, post-operative complications, and pathology results were recorded. Biopsy results were classified as diagnostic, inconclusive, or negative based on the final pathology. RESULTS Thirty patients undergoing MABC biopsies in the proximal arm or axilla and five patients with PFCN biopsies in the thigh or buttock were included. MABC biopsies were diagnostic in 70% of cases overall and 85% diagnostic in cases where pre-operative MRI also demonstrated abnormalities in the MABC. PFCN biopsies were diagnostic in 60% of cases overall and in 100% of patients with abnormal pre-operative MRIs. There were no biopsy-related post-operative complications in either group. CONCLUSIONS In diagnosing non-traumatic etiologies of brachial and lumbosacral plexopathies, proximal biopsies of the MABC and PFCN provide high diagnostic value with low donor morbidity.
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Affiliation(s)
- Kitty Y Wu
- Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Gonda 8-214, Rochester, MN, 55905, USA
| | - Nikhil K Murthy
- Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Gonda 8-214, Rochester, MN, 55905, USA
| | | | - P James B Dyck
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Robert J Spinner
- Department of Neurosurgery, Mayo Clinic, 200 First St. SW, Gonda 8-214, Rochester, MN, 55905, USA.
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19
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Hasrat NH, Kadhum HJ, Hashim AR, Yakob ZA, Farid HA. Clinical and Neurophysiological Evidence of Mononeuritis Multiplex During the COVID-19 Era. Cureus 2023; 15:e36853. [PMID: 37123696 PMCID: PMC10143078 DOI: 10.7759/cureus.36853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 03/31/2023] Open
Abstract
Infection with the novel coronavirus that causes coronavirus disease 2019 (COVID-19) results in a variety of clinical symptoms, including various neurological abnormalities. Peripheral nervous system symptoms, such as peripheral neuropathies, were often recorded in the medical literature, primarily as Guillain-Barré syndrome. Mononeuropathy multiplex is a multifocal axonal neuropathy commonly associated with vasculitis or connective tissue disease. Recent evidence about its associations with severe COVID-19 infection and intensive care unit hospitalization is being considered. A 58-year-old man with clinical and electrophysiological confirmation of mononeuropathy multiplex was reported during the peri-COVID-19 illness. He was treated with steroids and achieved a satisfactory response. Therefore, clinical and neurophysiological evaluation is recommended for any patient presenting with neurological manifestations following COVID-19 infection.
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20
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[Peripheral neuropathies during systemic diseases: Part II (vasculitis)]. Rev Med Interne 2023; 44:174-180. [PMID: 36925342 DOI: 10.1016/j.revmed.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/08/2023] [Indexed: 03/15/2023]
Abstract
Primary systemic vasculitides, mainly of the small and medium-sized vessels, are frequently associated with peripheral neuropathies. When the disease is already known, the appearance of a neuropathy should suggest a specific injury, especially when associated with other systemic manifestations. Conversely, when neuropathy is inaugural, close collaboration between neurologists and internists is necessary to reach a diagnosis. A standardized electro-clinical investigation specifying the topography, the evolution and the mechanism of the nerve damage enables the positive diagnosis of the neuropathy. Several elements orient the etiological diagnosis and allow to eliminate the main differential diagnosis: non systemic vasculitic neuropathy. The existence of associated systemic manifestations (glomerular or vascular nephropathy, interstitial lung disease, intra-alveolar hemorrhage, ENT involvement…), biological markers (ANCA, cryoglobulinemia, rheumatoid factor), and invasive examinations allowing histological analysis (neuromuscular biopsy) are all useful tools for.
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21
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Pacholczak-Madej R, Kosałka-Węgiel J, Kuszmiersz P, Mituś JW, Püsküllüoğlu M, Grela-Wojewoda A, Korkosz M, Bazan-Socha S. Immune Checkpoint Inhibitor Related Rheumatological Complications: Cooperation between Rheumatologists and Oncologists. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4926. [PMID: 36981837 PMCID: PMC10049070 DOI: 10.3390/ijerph20064926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 06/18/2023]
Abstract
In cancer, immune checkpoint inhibitors (ICIs) improve patient survival but may lead to severe immune-related adverse events (irAEs). Rheumatic irAEs are a distinct entity that are much more common in a real-life than in clinical trial reports due to their unspecific symptoms and them being a rare cause of hospitalization. This review focuses on an interdisciplinary approach to the management of rheumatic irAEs, including cooperation between oncologists, rheumatologists, and immunologists. We discuss the immunological background of rheumatic irAEs, as well as their unique clinical characteristics, differentiation from other irAEs, and treatment strategies. Importantly, steroids are not the basis of therapy, and nonsteroidal anti-inflammatory drugs should be administered in the front line with other antirheumatic agents. We also address whether patients with pre-existing rheumatic autoimmune diseases can receive ICIs and how antirheumatic agents can interfere with ICIs. Interestingly, there is a preclinical rationale for combining ICIs with immunosuppressants, particularly tumor necrosis factor α and interleukin 6 inhibitors. Regardless of the data, the mainstay in managing irAEs is interdisciplinary cooperation between oncologists and other medical specialties.
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Affiliation(s)
- Renata Pacholczak-Madej
- Department of Clinical Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, 33-332 Kraków, Poland
| | - Joanna Kosałka-Węgiel
- Department of Rheumatology and Immunology, Jagiellonian University Medical Kraków, 30-688 Krakow, Poland
- Division of Rheumatology and Immunology Clinical, University Hospital, 30-688 Kraków, Poland
| | - Piotr Kuszmiersz
- Department of Rheumatology and Immunology, Jagiellonian University Medical Kraków, 30-688 Krakow, Poland
- Division of Rheumatology and Immunology Clinical, University Hospital, 30-688 Kraków, Poland
| | - Jerzy W. Mituś
- Department of Anatomy, Jagiellonian University Medical College, 33-332 Kraków, Poland
- Department of Surgical Oncology, National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
| | - Mirosława Püsküllüoğlu
- Department of Clinical Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
| | - Aleksandra Grela-Wojewoda
- Department of Clinical Oncology, The Maria Skłodowska-Curie National Research Institute of Oncology, Kraków Branch, 31-115 Kraków, Poland
| | - Mariusz Korkosz
- Department of Rheumatology and Immunology, Jagiellonian University Medical Kraków, 30-688 Krakow, Poland
- Division of Rheumatology and Immunology Clinical, University Hospital, 30-688 Kraków, Poland
| | - Stanisława Bazan-Socha
- Department of Internal Medicine, Jagiellonian University Medical College, 30-688 Kraków, Poland
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22
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Rahbar M, Dolatkhah N. Vasculitis presenting as carpal tunnel syndrome: a case report. J Med Case Rep 2023; 17:84. [PMID: 36872340 PMCID: PMC9987105 DOI: 10.1186/s13256-023-03801-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/01/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Carpal tunnel syndrome is the most common focal mononeuropathy which presents with pain in the wrist and hand, paresthesia, loss of sensation in the distribution of the median nerve, and in more severe cases, weakness and atrophy of the thenar muscles. Meanwhile, carpal tunnel syndrome can present as an initial manifestation of underlying systemic vasculitis disorder and result in severe physical disabilities. CASE PRESENTATION A 27-year-old Iranian man was referred to our electrodiagnosis center with a clinical diagnosis of carpal tunnel syndrome in April 2020. Surgical intervention had been taken into account for him because of unsuccessful conservative therapies. On admission, thenar eminence was reduced. Electrodiagnostic findings were not compatible with median nerve entrapment at the wrist. All sensory modalities in the distribution of the right median nerve were decreased. Additionally, a mild increase in erythrocyte sedimentation rate was noted in laboratory tests. Because of the high vasculitis suspicion, we recommended the nerve biopsy and/or starting a high-dose corticosteroid. However, the surgery release was performed. After 6 months, the patient was referred for progressive weakness and numbness in the upper and lower limbs. After documentation of vasculitis neuropathy by biopsy, a diagnosis of non-systemic vasculitic neuropathy was confirmed. A rehabilitation program started immediately. Rehabilitation led to gradual improvement and recovery of function and muscle strength, and no complications remained, except mild leg paralysis. CONCLUSIONS Physicians should be suspicious of the median nerve vasculitis mononeuropathy in a patient with carpal tunnel syndrome-like symptoms. Median nerve vasculitis mononeuropathy as an initial presenting feature of vasculitis neuropathy can further result in severe physical impairments and disabilities.
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Affiliation(s)
- Mohammad Rahbar
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Neda Dolatkhah
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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23
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Mansueto G, Lanza G, Falleti J, Orabona P, Alaouieh D, Hong E, Girolami S, Montella M, Fisicaro F, Galdieri A, Singh P, Di Napoli M. Central and Peripheral Nervous System Complications of Vasculitis Syndromes from Pathology to Bedside: Part 2-Peripheral Nervous System. Curr Neurol Neurosci Rep 2023; 23:83-107. [PMID: 36820992 PMCID: PMC9947450 DOI: 10.1007/s11910-023-01249-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Peripheral nervous system vasculitides (PNSV) are a heterogeneous group of disorders with a clinical subset that may differ in prognosis and therapy. We provide a comprehensive update on the clinical assessment, diagnosis, complications, treatment, and follow-up of PNSV. RECENT FINDINGS Progress in neuroimaging, molecular testing, and peripheral nerve biopsy has improved clinical assessment and decision-making of PNSV, also providing novel insights on how to prevent misdiagnosis and increase diagnostic certainty. Advances in imaging techniques, allowing to clearly display the vessel walls, have also enhanced the possibility to differentiate inflammatory from non-inflammatory vascular lesions, while recent histopathology data have identified the main morphological criteria for more accurate diagnosis and differential diagnoses. Overall, the identification of peculiar morphological findings tends to improve diagnostic accuracy by defining a clearer boundary between systemic and non-systemic neuropathies. Therefore, the definition of epineurium vessel wall damage, type of vascular lesion, characterization of lymphocyte populations, antibodies, and inflammatory factors, as well as the identification of direct nerve damage or degeneration, are the common goals for pathologists and clinicians, who will both benefit for data integration and findings translation. Nevertheless, to date, treatment is still largely empiric and, in some cases, unsatisfactory, thus often precluding precise prognostic prediction. In this context, new diagnostic techniques and multidisciplinary management will be essential in the proper diagnosis and prompt management of PNSV, as highlighted in the present review. Thirty to fifty percent of all patients with vasculitis have signs of polyneuropathy. Neuropathies associated with systemic vasculitis are best managed according to the guidelines of the underlying disease because appropriate workup and initiation of treatment can reduce morbidity. Steroids, or in severe or progressive cases, cyclophosphamide pulse therapy is the standard therapy in non-systemic vasculitic neuropathies. Some patients need long-term immunosuppression. The use of novel technologies for high-throughput genotyping will permit to determine the genetic influence of related phenotypes in patients with PNSV.
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Affiliation(s)
- Gelsomina Mansueto
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Piazza L. Miraglia 2, 80138, Naples, Italy.,Clinical Department of Laboratory Services and Public Health-Legal Medicine Unit, University of Campania "Luigi Vanvitelli", Via Luciano Armanni 5, 80138, Naples, Italy.,Pathology-Unit of Federico II University, Via S. Pansini 3, 80131, Naples, Italy
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy.,Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Via Conte Ruggero 73, 94018, Troina, Italy
| | - Jessica Falleti
- Pathology Unit, Sant'Anna E San Sebastiano Hospital, 81100, Caserta, Italy
| | - Pasquale Orabona
- Pathology Unit, Sant'Anna E San Sebastiano Hospital, 81100, Caserta, Italy
| | | | - Emily Hong
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Sara Girolami
- Neurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039, Sulmona, L'Aquila, Italy
| | - Marco Montella
- Mental and Physical Health and Preventive Medicine Department, University of Campania "Luigi Vanvitelli", Via Luciano Armanni 5, 80138, Naples, Italy
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123, Catania, Italy
| | - Anna Galdieri
- AOU "Luigi Vanvitelli", Via Santa Maria Di Costantinopoli 104, 80138, Naples, Italy
| | - Puneetpal Singh
- Department of Human Genetics, Punjabi University, Patiala, 147002, Punjab, India
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039, Sulmona, L'Aquila, Italy.
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24
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Duchesne M. [Nerve biopsy in the diagnosis of peripheral neuropathies]. Ann Pathol 2023; 43:83-95. [PMID: 36522247 DOI: 10.1016/j.annpat.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 10/22/2022] [Accepted: 11/01/2022] [Indexed: 12/15/2022]
Abstract
The indications for nerve biopsy have diminished in recent years. This examination nevertheless remains essential in certain cases of peripheral neuropathies, making it possible to specify the diagnosis or the mechanism of injury for a therapeutic purpose. It is a simple but "invasive" procedure, which can only be performed once on the same nerve. The indications are thus discussed on a case-by-case basis and based on a range of clinical, electrophysiological, biological or even genetic arguments. This involves close collaboration between clinical physicians and pathologists. The main difficulty of this biopsy concerns the fragility of the sample and the techniques necessary for its interpretation, requiring it to be carried out in expert centers. Nerve biopsy is closely related to skin biopsy in the search for small fiber neuropathy. It is a particular technique, but very well codified. The purpose of this review is to recall the indications and contraindications of nerve biopsy, and to explain what the contributions are but also the limits of this examination as well as of skin biopsy.
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Affiliation(s)
- Mathilde Duchesne
- Laboratoire de neurologie, CHU de Limoges, CHU de Dupuytren, Centre de référence neuropathies périphérique rares, 2, avenue Martin-Luther-King, 87000 Limoges, France; Service d'anatomo-pathologie, CHU de Dupuytren, bâtiment CBRS, rue du Professeur Descottes, 87000 Limoges, France.
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25
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Magy L, Duchesne M, Frachet S, Vallat JM. Neuropatie periferiche. Neurologia 2023. [DOI: 10.1016/s1634-7072(22)47358-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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26
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Restoring the function in neuralgic shoulder amyotrophy by modified Somsak nerve transfer. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
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Vitali F, Sciarrone MA, Frisullo G, Fedele AL, Torchia E, Tasca G, Luigetti M. ANCA-negative microscopic polyangiitis with neuromuscular involvement: When pathology could make the difference. Clin Neurol Neurosurg 2023; 225:107573. [PMID: 36608469 DOI: 10.1016/j.clineuro.2022.107573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/08/2022] [Accepted: 12/22/2022] [Indexed: 12/25/2022]
Abstract
Microscopic polyangiitis (MPA) is a necrotizing small vessel vasculitis with little or absent immune deposits (pauci-immune vasculitis), usually associated with the presence of antineutrophil cytoplasmic autoantibodies (ANCA) and a wide spectrum of organ manifestations. In our report we describe the case of a 74-year-old Asian man, who rapidly developed lower limb weakness and impaired renal and pulmonary functions. ANCA detection remained borderline throughout the disease course. Electrophysiological and instrumental studies revealed a picture of neuromuscular involvement; renal and muscle biopsies disclosed a small vessel vasculitis. He was started on a targeted immunosuppressive combination therapy and his clinical status progressively improved. In the framework of a multi-organ disease, microscopic polyangiitis should be considered as a differential diagnosis in case of acute/subacute onset of muscle weakness, even in the absence of ANCA detection.
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Affiliation(s)
- Francesca Vitali
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, L.go A. Gemelli 8, Roma, Lazio 00168, Italy.
| | - Maria Ausilia Sciarrone
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, L.go A. Gemelli 8, Roma, Lazio 00168, Italy
| | - Giovanni Frisullo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, L.go A. Gemelli 8, Roma, Lazio 00168, Italy
| | - Anna Laura Fedele
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Reumatologia, L.go A Gemelli 8, Roma, Lazio 00168, Italy
| | - Eleonora Torchia
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, L.go A. Gemelli 8, Roma, Lazio 00168, Italy
| | - Giorgio Tasca
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, L.go A. Gemelli 8, Roma, Lazio 00168, Italy
| | - Marco Luigetti
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, L.go A. Gemelli 8, Roma, Lazio 00168, Italy
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Lee LY, Tan CY, Wong KT, Goh KJ, Shahrizaila N. Diagnostic yield of nerve biopsy in the evaluation of peripheral neuropathies. J Clin Neurosci 2023; 107:40-47. [PMID: 36502780 DOI: 10.1016/j.jocn.2022.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND With progress made in neurogenetics and neuroinflammation, the indications and value of nerve biopsies in the diagnostic evaluation of peripheral neuropathies are less clear. In this study, we aimed to evaluate the diagnostic yield of nerve biopsies in patients with peripheral neuropathies. METHODS We performed a retrospective review of nerve biopsy reports from April 1998 to June 2021 of patients with peripheral neuropathies presenting to the Department of Pathology, University of Malaya Medical Centre, Kuala Lumpur, Malaysia. The diagnostic value of the biopsies was determined based on the criteria by Midroni and Bilbao as follows: contributive (essential and helpful), non-contributive and inadequate. RESULTS A total of 107 nerve biopsies were analysed. Sixty-four (60 %) were males and the mean age was 52 years, ranging from 13 to 86 years. Ninety-four (88 %) were sural nerve biopsies; and only one patient (1 %) each had superficial peroneal and superficial radial nerve biopsy. The indications for the procedure were vasculitis (34 %), peripheral neuropathy of unknown aetiology (34 %), amyloidosis (14 %) and chronic inflammatory demyelinating polyneuropathy (10 %). In 68 (63 %) biopsies, the diagnostic value was contributive. Of these, 28 (26 %) were essential and 40 (37 %) were helpful. In contrast, 35 (33 %) biopsies were non-contributive and 4 (4 %) were inadequate. In 66 % (71/107) of cases, the nerve biopsy did not reveal a definite pathological diagnosis. However, in the remainder, a diagnosis of vasculitis (18 %, 19/107), followed by amyloidosis (10 %, 11/107) could be determined. For 32/71 biopsies with undetermined pathological diagnosis, neuropathy remained cryptogenic in 22 % (7/32) upon follow up. CONCLUSIONS With the exception of vasculitis and amyloidosis, there is limited value in performing nerve biopsies in the evaluation of patients with peripheral neuropathy. However, this should be interpreted with caution as the number of patients with a clinical diagnosis of vasculitis and amyloidosis were relatively larger than patients with other diagnosis. Refinement and careful selection of cases are required to increase the diagnostic yield of nerve biopsy.
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Affiliation(s)
- Ling Yi Lee
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Cheng Yin Tan
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Kum Thong Wong
- Department of Pathology, University of Malaya, Kuala Lumpur, Malaysia
| | - Khean Jin Goh
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nortina Shahrizaila
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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29
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Younger DS. Adult and childhood vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:653-705. [PMID: 37562892 DOI: 10.1016/b978-0-323-98818-6.00008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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30
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Davalos L, Watanabe M, Gallagher GW, Grewal A, Fudym Y, Reynolds EL, Callaghan BC, Banarjee M, London ZN. Diagnostic characteristics of nerve conduction study parameters for vasculitic neuropathy. Muscle Nerve 2023; 67:45-51. [PMID: 36367146 PMCID: PMC10100037 DOI: 10.1002/mus.27753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 10/30/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION/AIMS In vasculitic neuropathy (VN), a 50% side-to-side difference in the amplitude of compound muscle action potentials and sensory nerve action potentials is considered meaningful, but unequivocal evidence is lacking. The aim of this study is to characterize electrodiagnostic features that best distinguish VN from other axonal polyneuropathies. METHODS We conducted a case-control study between January 2000 and April 2021. We reviewed the records of patients with VN who had bilateral nerve conduction studies (NCS) and evaluated different electrodiagnostic models to help distinguish VN from non-inflammatory axonal polyneuropathies. RESULTS We identified 82 cases, and 174 controls with non-inflammatory axonal neuropathies. The amplitude percent difference Z-score model showed the best discriminatory capability between cases and controls (area under the curve [AUC] 0.87; 95% confidence interval [CI] 0.82, 0.93), and the number of nerves tested did not significantly influence the model. Individually, the ulnar motor nerve (AUC 0.86; 95% CI 0.77, 0.94) and median motor nerve (AUC 0.85; 95% CI 0.77, 0.94) showed the best discriminatory capability. A 50% amplitude difference between at least two bilateral nerves, either in the upper (AUC 0.85; 95% CI 0.77, 0.93) or lower (AUC 0.79; 95% CI 0.71, 0.87) extremity showed good discriminatory threshold for detecting VN. DISCUSSION The best electrodiagnostic criteria for VN utilizes z-scores of percent differences in nerve amplitudes, but this approach may be difficult to implement at the bedside. Alternately, a 50% amplitude difference in at least two nerves is a reasonable approximation.
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Affiliation(s)
- Long Davalos
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Maya Watanabe
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Gary W Gallagher
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Avneet Grewal
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Yelena Fudym
- Department of Pathology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Evan L Reynolds
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Brian C Callaghan
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Mousumi Banarjee
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Zachary N London
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
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Aladawi M, Shelly S, Dyck PJB, Koster M, Engelstad J, Piccione EA, Naddaf E. Nitrofurantoin and Minocycline-Associated Vasculitic Neuropathy: Case Reports and Literature Review. J Clin Neuromuscul Dis 2022; 24:85-94. [PMID: 36409339 DOI: 10.1097/cnd.0000000000000404] [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: 06/16/2023]
Abstract
BACKGROUND Vasculitic neuropathies usually present acutely to subacutely, with an asymmetric pattern, involving multiple peripheral nerve territories. Drug-induced vasculitis is an often overlooked etiology of vasculitic neuropathy. METHODS We present the first reported case of nitrofurantoin-associated and an illustrative case of minocycline-associated vasculitic neuropathy, with a review of the literature. RESULTS The first patient is a 60-year-old woman who developed axonal sensorimotor peripheral neuropathy after nitrofurantoin use, with a superficial radial nerve biopsy confirming vasculitis. The second patient is a 23-year-old woman, with a history of acne vulgaris treated with minocycline, who presented with a subacute right common peroneal mononeuropathy followed by a left deep peroneal mononeuropathy, with elevated antinuclear, perinuclear-antineutrophil cytoplasmic, and myleoperoxidase antibodies, and MPO titers, and a sural nerve biopsy showing large arteriole vasculitis. Finally, we provide a comprehensive review of previously published cases. CONCLUSIONS Medications should be considered as a trigger for medication-induced vasculitic neuropathy. Accurate diagnosis would ensure timely treatment.
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Affiliation(s)
- Mohammad Aladawi
- Departement of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | | | | | - Matthew Koster
- Deparmtent of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN; and
| | - JaNean Engelstad
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ezequiel A Piccione
- Departement of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, MN
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Takeuchi H, Kawamura K, Kawasaki T, Oka N. Distinct features of hypereosinophilic syndrome with neuropathy from eosinophilic granulomatosis with polyangiitis. Front Neurol 2022; 13:1057767. [PMID: 36457867 PMCID: PMC9705778 DOI: 10.3389/fneur.2022.1057767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/28/2022] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hypereosinophilic syndrome (HES) and eosinophilic granulomatosis with polyangiitis (EGPA) have overlapping clinical considerations, which frequently involve peripheral neuropathy. The current study aimed to discriminate between the clinicopathological features of HES and EGPA, focusing on the mechanism of peripheral nerve damage. METHODS A total of 53 patients who underwent nerve biopsies at our laboratory were examined: nine patients with idiopathic HES (iHES), three patients with reactive HES, 14 patients with myeloperoxidase-anti-neutrophil cytoplasmic antibody (ANCA)-positive EGPA, and 27 patients with negative EGPA. Nerve biopsies were performed using light and electron microscopy. RESULTS Polyneuropathy was more common than mononeuritis multiplex in iHES, which differed from that in ANCA-negative EGPA groups (p = 0.012). Nerve biopsies showed that iHES was associated with neuropathy features such as rare vasculitis and non-vasculitic eosinophilic infiltrates, which differed from those of ANCA-negative EGPA. Fibrinoid necrosis was found only in the reactive HES and ANCA-positive groups. The percentage of endoneurial vessels occluded with eosinophils tended to be higher in iHES (1.8%) than in ANCA-positive EGPA (0%) and negative EGPA (0.7%). In a patient with ANCA-negative EGPA, the endoneurial vessels were occluded with platelets, fibrinoid materials, and eosinophils, demonstrating the morphology of eosinophil extracellular traps. CONCLUSION iHES with neuropathy showed a pattern more similar to polyneuropathy than mononeuritis multiplex, which is dominant in ANCA-negative EGPA, and tended to show vasculitis in the peripheral nerves less frequently compared with EGPA. Eosinophilic infiltration and endoneurial vascular occlusion by eosinophils may cause nerve damage.
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Affiliation(s)
- Hiroki Takeuchi
- Department of Neurology, National Hospital Organization Minami Kyoto Hospital, Kyoto, Japan
| | - Kazuyuki Kawamura
- Department of Neurology, National Hospital Organization Minami Kyoto Hospital, Kyoto, Japan
| | - Teruaki Kawasaki
- Kyoto Clinical and Translational Research Center for Neurocognitive Disorders, Kyoto, Japan
| | - Nobuyuki Oka
- Department of Neurology, National Hospital Organization Minami Kyoto Hospital, Kyoto, Japan
- Department of Neurology, Kyoto Konoe Rehabilitation Hospital, Kyoto, Japan
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Masuda Y, Matsuda S, Kotani T, Nishioka D, Ota S, Hosokawa T, Ishida S, Takeuchi T. Association between Serum Biomarkers and Peripheral Neuropathy in Microscopic Polyangiitis. Int J Mol Sci 2022; 23:13374. [PMID: 36362162 PMCID: PMC9658745 DOI: 10.3390/ijms232113374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/14/2023] Open
Abstract
This study aimed to elucidate the pathomechanism of peripheral neuropathy (PN) in microscopic polyangiitis (MPA) and to identify biomarkers useful for diagnosis and severity assessment. Patients with MPA (n = 37) and other non-inflammatory neurological diseases (ONDs; n = 12) were enrolled, and the peripheral nerves of all patients were evaluated using nerve conduction studies. We compared the clinical characteristics and 14 serum biomarker profiles among patients with MPA and PN, MPA without PN, and ONDs. Patients with MPA had a higher prevalence of motor neuropathy than patients with ONDs. Among the patients with MPA, those with motor neuropathy had significantly higher total Birmingham Vasculitis Activity Scores and serum levels of C-reactive protein (CRP), tissue inhibitor of metalloproteinase-1 (TIMP-1), and interleukin-6 than patients without motor neuropathy. Multivariable analyses adjusted for age, serum CRP level, and diabetes mellitus showed that high serum levels of TIMP-1 were independently related to a diagnosis of motor neuropathy in MPA. Additionally, there were significant negative correlations between the serum levels of TIMP-1 and compound muscle action potential amplitudes. Serum levels of TIMP-1 may be associated with the pathomechanism of motor neuropathy in MPA and could be a useful biomarker for diagnosing and evaluating the severity of motor neuropathy in MPA.
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Affiliation(s)
- Yuichi Masuda
- Division of Neurology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Shogo Matsuda
- Division of Rheumatology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Takuya Kotani
- Division of Rheumatology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Daisuke Nishioka
- Research & Development Center, Department of Medical Statistics, Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Shin Ota
- Division of Neurology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Takafumi Hosokawa
- Division of Neurology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Shimon Ishida
- Division of Neurology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
| | - Tohru Takeuchi
- Division of Rheumatology, Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka 569-1094, Japan
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Fukami Y, Koike H, Katsuno M. Current perspectives on the diagnosis, assessment, and management of vasculitic neuropathy. Expert Rev Neurother 2022; 22:941-952. [PMID: 36609209 DOI: 10.1080/14737175.2022.2166831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Vasculitic neuropathy can present associated with both primary and secondary systemic vasculitis as a result from underlying diseases such as rheumatic diseases and infections, Moreover, confined vasculitis in the peripheral nervous system may be present. Thus, the diagnosis and management of vasculitic neuropathy require multidisciplinary approaches. AREAS COVERED Current views as well as relevant clinical research on the diagnosis, assessment, and management of vasculitic neuropathy are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for reports published between July 2017 and July 2022. EXPERT OPINION For the treatment of vasculitic neuropathy, determining the causative primary disease is important and often requires diagnosis by tissue biopsy. Due to the scarce research on the treatment of vasculitic neuropathy, treatment is empirically based on findings from studies of systemic vasculitides involving other organs, particularly antineutrophil cytoplasmic antibody-associated vasculitis. In addition to conventional glucocorticoids and immunosuppressive agents, complement-targeted therapy, anti-B-cell therapy, and disease-specific molecular targeted therapies have recently gained relevance. Future research is needed to develop new patient-specific therapeutic options.
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Affiliation(s)
- Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Clinical Research Education, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Zaottini F, Picasso R, Pistoia F, Sanguinetti S, Pansecchi M, Tovt L, Viglino U, Cabona C, Garnero M, Benedetti L, Martinoli C. High-resolution ultrasound of peripheral neuropathies in rheumatological patients: An overview of clinical applications and imaging findings. Front Med (Lausanne) 2022; 9:984379. [PMID: 36388946 PMCID: PMC9661426 DOI: 10.3389/fmed.2022.984379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Peripheral neuropathies are surprisingly common and can be associated with a number of conditions, including rheumatological diseases. Whether the co-existence of peripheral neuropathies with rheumatological disorders is coincidental or related to a common pathogenic mechanism, these disabling conditions can affect the outcome of rheumatological patients and should be targeted with specific treatment. The clinical presentation of peripheral neuropathy can be multifaceted and difficult to recognize in polysymptomatic patients. However, physicians adopting state-of-art diagnostic strategies, including nerve imaging, may improve the detection rate and management of neuropathies. In particular, a diagnostic approach relying exclusively on clinical history and nerve conduction studies may not be sufficient to disclose the etiology of the nerve damage and its anatomical location and thus requires integration with morphological studies. High-Resolution Ultrasound (HRUS) is increasingly adopted to support the diagnosis and follow-up of both joint disorders in rheumatology and peripheral neuropathies of different etiologies. In this review, the different types of nerve disorders associated with the most common syndromes of rheumatological interest are discussed, focusing on the distinctive sonographic features.
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Affiliation(s)
- Federico Zaottini
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Riccardo Picasso
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- *Correspondence: Riccardo Picasso,
| | - Federico Pistoia
- Dipartimento di Medicina Sperimentale, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Sara Sanguinetti
- Dipartimento di Medicina Sperimentale, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Michelle Pansecchi
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Luca Tovt
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Umberto Viglino
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Corrado Cabona
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Eye Clinic, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Science, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy
| | - Martina Garnero
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Eye Clinic, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Science, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy
| | - Luana Benedetti
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Eye Clinic, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Science, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy
| | - Carlo Martinoli
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
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Schneider C, Wassermann MK, Fink GR, Lehmann HC. Single-center experience of induction therapy in non-systemic vasculitic neuropathy. Neurol Res Pract 2022; 4:32. [PMID: 35965348 PMCID: PMC9377119 DOI: 10.1186/s42466-022-00198-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background No controlled studies for non-systemic vasculitic neuropathy treatment exist (NSVN). We compared the treatment response to induction therapy commonly used in clinical practice in NSVN. Methods In this retrospective single-center study, 43 patients with biopsy-proven NSVN were analyzed. Patients were subdivided into groups depending on their initial treatment. Relapse rates, changes of motor and sensory symptoms, adverse events, predictors of relapses, and second-line treatment were compared. Results Initial treatment regimens were corticosteroid monotherapy, cyclophosphamide monotherapy, pulsed corticosteroid therapy, and combination therapy. Discontinuation due to adverse events occurred in 6 of 43 patients. Clinical data did not differ between treatment groups. Within 12 months, 24.3% of patients relapsed. The median time to relapse was 4 (1.5, 6) months. No relapse occurred in the combination therapy group. However, there was no statistically significant difference in relapse-free survival between treatment groups (p = 0.58). Neither clinical data nor biopsy analysis predicted relapses sufficiently. As a second-line treatment, cyclophosphamide as mono- or combination therapy was used (7 of 9 patients) most frequently. One patient was treated with methotrexate, and one with IVIG. Conclusions Induction therapy used in clinical practice is effective and mainly well-tolerated in NSVN. Our data do not support an overall advantage of cyclophosphamide over corticosteroid monotherapy. Controlled trials comparing the effectiveness of induction and maintenance therapy in NSVN are warranted.
Supplementary Information The online version contains supplementary material available at 10.1186/s42466-022-00198-5.
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Koike H, Furukawa S, Mouri N, Fukami Y, Iijima M, Katsuno M. Early ultrastructural lesions of anti-neutrophil cytoplasmic antibody- versus complement-associated vasculitis. Neuropathology 2022; 42:420-429. [PMID: 35707831 DOI: 10.1111/neup.12821] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/24/2022] [Accepted: 05/01/2022] [Indexed: 12/11/2022]
Abstract
This study aims to describe electron microscopic findings of vasculitis associated with anti-neutrophil cytoplasmic antibody (ANCA) and complement. Sural nerve biopsy specimens were obtained from 10 patients with microscopic polyangiitis (MPA), a representative ANCA-associated vasculitis, and six patients with nonsystemic vasculitic neuropathy (NSVN), who were negative for ANCA but positive for complement deposition. In patients with MPA, attachment of neutrophils to epineurial vascular endothelial cells, migration of neutrophils to the extravascular space via the penetration of the endothelial layer, and release of neutrophil components to the extracellular space were observed. Such neutrophil-associated lesions were not observed in patients with NSVN. Nonetheless, morphological changes in epineurial vascular endothelial cells, such as increases in cytoplasmic organelles and cytoplasmic protrusions into the vascular lumen, were observed in patients with NSVN. Since these findings were observed where light microscopy-based findings suggestive of vasculitis (e.g., the disruption of vascular structures and fibrinoid necrosis) were absent, they were considered early lesions that preceded the formation of the so-called necrotizing vasculitis. In conclusion, this study enabled the visualization of distinctive early ultrastructural lesions associated with ANCA and complement. Further studies are needed to elucidate the molecular basis of the induction of these fine structural changes, which will contribute to the development of targeted therapies based on specific mechanisms of vasculitis.
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Affiliation(s)
- Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Soma Furukawa
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naohiro Mouri
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiro Iijima
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Du K, Chu X, Tang Y, Zhao X, Yu M, Zheng Y, Deng J, Lv H, Zhang W, Wang Z, Yuan Y, Meng L. Patterns of myelinated nerve fibers loss in transthyretin amyloid polyneuropathy and mimics. Ann Clin Transl Neurol 2022; 9:1059-1068. [PMID: 35665499 PMCID: PMC9268867 DOI: 10.1002/acn3.51599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/02/2022] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
Objective The present study was intended to analyze the characteristics of myelinated nerve fibers density (MFD) of transthyretin amyloid polyneuropathy (ATTR‐PN) and other similar neuropathies. Methods A total of 41 patients with ATTR‐PN, 58 patients of other common peripheral neuropathies, and 17 age‐and gender‐matched controls who visited the First Hospital of Peking University and performed sural nerve biopsy between June 2007 and August 2021 were included for analysis of MFD. Results Except the vasculitic neuropathy group, the total and small MFD of patients in the ATTR‐PN group were significantly lower than those of other disease groups. There was an obvious negative correlation between the total MFD and the disease course in the ATTR‐PN group. The disease course of early‐onset and late‐onset symptoms was similar, but the loss of large myelinated nerve fibers (MF) was more severe for the latter. In addition, all late‐onset and most early‐onset patients had severely reduced MFD after a 2 years' disease course. The MFD in ATTR‐PN patients was negatively correlated with Neuropathy Impairment Score (NIS) and Norfolk Quality of life‐diabetic neuropathy (Norfolk QOL‐DN) score. Conclusion MF is lost differently in ATTR‐PN and in other common peripheral neuropathies. The late‐onset and early‐onset ATTR‐PN patients have different patterns of loss of large and small MF.
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Affiliation(s)
- Kang Du
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Xujun Chu
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Yuwei Tang
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Xutong Zhao
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Meng Yu
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Yiming Zheng
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Jianwen Deng
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - He Lv
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Wei Zhang
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Zhaoxia Wang
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
| | - Yun Yuan
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
- Beijing Key Laboratory of Neurovascular Disease Discovery Beijing 100034 China
| | - Lingchao Meng
- Department of Neurology Peking University First Hospital 8 Xishiku Street, Xicheng District Beijing 100034 China
- Beijing Key Laboratory of Neurovascular Disease Discovery Beijing 100034 China
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Gisslander K, Dahlin LB, Smith R, Jayne D, O'Donovan DG, Mohammad AJ. The role of sural nerve biopsy in diagnosis of vasculitis. J Rheumatol 2022; 49:1031-1036. [PMID: 35649553 DOI: 10.3899/jrheum.211406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The diagnostic yield of sural nerve biopsy (SNB) in vasculitis is uncertain. Our aim was to document relevant characteristics of patients undergoing sural nerve biopsy in the investigation of vasculitis; determine the diagnostic yield; relate positive biopsy findings to patient demographic, laboratory, and clinical parameters; and to calculate the rate of surgical complications. METHODS Patients with suspected vasculitis that underwent SNB as part of diagnostic evaluation at academic medical centres in Sweden and the United Kingdom were identified by searching local pathology databases and clinic registers. A structured review of medical case records and pathology reports was conducted. Histological findings were categorized as definite, probable, or no vasculitis in accordance with the 2015 Brighton Collaboration reinterpretation and update of the Peripheral Nerve Society Guidelines for Vasculitic Neuropathy. Definite and probable findings were considered positive for vasculitis. RESULTS Ninety-one patients that underwent SNB were identified (45% female). Forty (44%) showed histological evidence of vasculitis: 14 definite and 26 probable. A concomitant muscle biopsy conducted in 10 patients did not contribute to the diagnostic yield. Positive antineutrophil cytoplasmic antibody test, organ involvement other than the nervous system, and a longer biopsy sample were associated with a positive biopsy. The reported surgical complication rate was 15%. CONCLUSION Sural nerve biopsy of sufficient length is an expedient procedure to confirm a diagnosis of vasculitis.
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Affiliation(s)
- Karl Gisslander
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
| | - Lars B Dahlin
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
| | - Rona Smith
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
| | - David Jayne
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
| | - Dominic G O'Donovan
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
| | - Aladdin J Mohammad
- Department of Rheumatology, Lund University, Lund, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden; Department of Medicine, Vasculitis and Lupus Research Group, University of Cambridge, Cambridge, United Kingdom;Department of Neuropathology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom. This study was supported by grants from the Swedish Research Council (Vetenskapsrådet: 2019-01655), Faculty of Medicine, Lund University (ALF-medel). Correspondence to Karl Gisslander, Department of Rheumatology, Department of Medicine, Lund University 221 85 Lund;
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Fukami Y, Koike H, Iijima M, Mouri N, Nishi R, Katsuno M. Role of complement components in vasculitic neuropathy associated with systemic lupus erythematosus and rheumatoid arthritis. Muscle Nerve 2022; 66:175-182. [PMID: 35581952 DOI: 10.1002/mus.27636] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 05/08/2022] [Accepted: 05/15/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION/AIMS The mechanism of complement-mediated neurological injury in vasculitic neuropathy associated with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) is unknown. The current study aimed to investigate the local activation of the complement system in vasculitic neuropathy associated with SLE and RA. METHODS We analyzed sural nerve biopsy specimens collected from patients with SLE (n = 12) and RA (n = 12). The deposition of complement components comprising the classical and lectin pathways was assessed via immunohistochemistry. RESULTS The disease duration was longer in the RA group than in the SLE group (median [interquartile range]: 11.5 [5.5-31.0] and 4 [2-10] y, respectively). Complement components were found in the epineurial blood vessel walls in patients with SLE and RA, but not in controls. Deposition of the classical pathway component C1q in the blood vessel wall was more commonly observed in the SLE group (71.3% [25.6-85.8]) than in the RA group (20.1% [10.5-35.6]). As for the lectin pathway component, the incidence of ficolin-3 deposition in the blood vessel wall was higher in the SLE group (42.3% [25.7-51.3]) than in the RA group (17.2% [10.3-26.8]). On the contrary, the mannose-binding lectin level was higher in the RA group (37.5% [21.7-51.4]) than in the SLE group (17.8% [11.4-31.0]). DISCUSSION The classical and lectin pathways of the complement system may be involved in vasculitic neuropathy associated with SLE and RA.
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Affiliation(s)
- Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiro Iijima
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Division of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Naohiro Mouri
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryoji Nishi
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Neurology, Daido Hospital, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Clinical Research Education, Nagoya University Graduate School of Medicine, Nagoya, Japan
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In vivo visualization of eosinophil secretion in eosinophilic granulomatosis with polyangiitis: An ultrastructural study. Allergol Int 2022; 71:373-382. [PMID: 35428588 DOI: 10.1016/j.alit.2022.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although eosinophilic granulomatosis with polyangiitis (EGPA) has been considered as a single disease entity belonging to anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, several studies have suggested that in addition to the mechanisms associated with ANCA, those associated with eosinophils play a vital role in tissue damage. Nevertheless, the morphological bases underlying eosinophil-associated lesions have not been completely elucidated. METHODS We investigated the electron microscopic findings of sural nerve biopsy specimens obtained from 18 patients with EGPA by focusing on the behavior of eosinophils, particularly the mode of secretion. RESULTS Eosinophils tended to be located at sites close to endothelial cells within the lumina of epineurial small vessels. Attachment of eosinophils to endothelial cells was observed, particularly at the junction between neighboring endothelial cells, and some of these eosinophils appeared to escape from the vascular lumen to migrate into the extravascular interstitium. Furthermore, we observed eosinophil degranulation via piecemeal degranulation and cytolysis. Degranulating eosinophils were identified in both intravascular and extravascular compartments. Some of the small vessels appeared to be occluded by numerous eosinophils, and eosinophils attached by platelets were also observed, suggesting that coagulopathy occurs in EGPA. CONCLUSIONS Both extravascular and intravascular eosinophils can induce tissue damage unrelated to classical necrotizing vasculitis associated with ANCA in patients with EGPA. Further research is necessary to elucidate the molecular basis of the induction of these fine structural changes, which will contribute to the development of targeted therapies based on specific mechanisms of eosinophil-related diseases.
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Koike H, Nishi R, Ohyama K, Morozumi S, Kawagashira Y, Furukawa S, Mouri N, Fukami Y, Iijima M, Sobue G, Katsuno M. ANCA-Associated Vasculitic Neuropathies: A Review. Neurol Ther 2022; 11:21-38. [PMID: 35044596 PMCID: PMC8857368 DOI: 10.1007/s40120-021-00315-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/08/2021] [Indexed: 01/21/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis is a systemic disorder that frequently affects the peripheral nervous system and consists of three distinct conditions: microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA, previously Wegener’s granulomatosis), and eosinophilic granulomatosis with polyangiitis (EGPA, previously Churg-Strauss syndrome). The neuropathic features associated with this condition usually include mononeuritis multiplex, which reflects the locality of lesions. Findings suggestive of vasculitis are usually found in the epineurium and occur diffusely throughout the nerve trunk. Nerve fiber degeneration resulting from ischemia is sometimes focal or asymmetric and tends to become conspicuous at the middle portion of the nerve trunk. The attachment of neutrophils to endothelial cells in the epineurial vessels is frequently observed in patients with ANCA-associated vasculitis; neutrophils play an important role in vascular inflammation by binding of ANCA. The positivity rate of ANCA in EGPA is lower than that in MPA and GPA, and intravascular and tissue eosinophils appear to participate in neuropathy. Immunotherapy for ANCA-associated vasculitis involves the induction and maintenance of remission to prevent the relapse of the disease. A combination of glucocorticoids along with cyclophosphamide, rituximab, methotrexate, or mycophenolate mofetil is considered depending on the severity of the condition of the organ to induce remission. A combination of low-dose glucocorticoids and azathioprine, rituximab, methotrexate, or mycophenolate mofetil is recommended to maintain remission. The efficacy of anti-interleukin-5 therapy (i.e., mepolizumab) was demonstrated in the case of refractory or relapsing EGPA. Several other new agents, including avacopan, vilobelimab, and abatacept, are under development for the treatment of ANCA-associated vasculitis. Multidisciplinary approaches are required for the diagnosis and management of the disorder because of its systemic nature. Furthermore, active participation of neurologists is required because the associated neuropathic symptoms can significantly disrupt the day-to-day functioning and quality of life of patients with ANCA-associated vasculitis.
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Affiliation(s)
- Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan.
| | - Ryoji Nishi
- Department of Neurology, Daido Hospital, Nagoya, Japan
| | - Ken Ohyama
- Department of Neurology, Okazaki City Hospital, Okazaki, Japan
| | - Saori Morozumi
- Department of Neurology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | | | - Soma Furukawa
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Naohiro Mouri
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Masahiro Iijima
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
| | - Gen Sobue
- Aichi Medical University, Nagakute, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
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Sim NK, Ismail A, Alam T, Shanmugarajah PD. Adalimumab-induced sensory vasculitic neuropathy. BMJ Case Rep 2022; 15:e246401. [PMID: 35039360 PMCID: PMC8768498 DOI: 10.1136/bcr-2021-246401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/03/2022] Open
Abstract
Vasculitis and other autoimmune conditions are known complications of tumour necrosis factor alpha (TNF-α) inhibitor use. By definition, TNF-α inhibitor induced vasculitis is a secondary systemic vasculitis. However, its phenotype is varied and can present as an isolated vasculitic neuropathy. This presents a diagnostic challenge as the gold standard for diagnosis of a vasculitic neuropathy is a peripheral nerve biopsy that meets predefined histopathological criteria. Given the poor sensitivity of the peripheral nerve biopsy, it is important that clinicians take a good history and maintain a high index of suspicion, as this is a treatable iatrogenic condition. Here we present a case of adalimumab-induced sensory vasculitic neuropathy, treated according to the Peripheral Nerve Society guideline for non-systemic vasculitic neuropathy, given her disease phenotype.
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Affiliation(s)
- Nicholas Keyi Sim
- Department of Neurology, Calderdale and Huddersfield NHS Foundation Trust, Halifax, UK
| | - Azzam Ismail
- Department of Pathology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Taimour Alam
- Department of Clinical Neurophysiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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El-Abassi RN, Soliman M, Levy MH, England JD. Treatment and Management of Autoimmune Neuropathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Ducci RDP, Tessaro CL, Kay CSK, Fustes OJH, Werneck LC, Lorenzoni PJ, Scola RH. Peripheral polyneuropathy from electrodiagnostic tests: a 10-year etiology and neurophysiology overview. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 80:270-279. [PMID: 34816968 DOI: 10.1590/0004-282x-anp-2020-0561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/21/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Polyneuropathies are characterized by a symmetrical impairment of the peripheral nervous system, resulting in sensory, motor and/or autonomic deficits. Due to the heterogeneity of causes, an etiological diagnosis for polyneuropathy is challenging. OBJECTIVE The aim of this study was to determine the main causes of polyneuropathy confirmed by electrodiagnostic (EDX) tests in a tertiary service and its neurophysiological aspects. METHODS This observational cross-sectional study from a neuromuscular disorders center included individuals whose electrodiagnostic tests performed between 2008 and 2017 confirmed a diagnosis of polyneuropathy. Through analysis of medical records, polyneuropathies were classified according to etiology and neurophysiological aspect. RESULTS Of the 380 included patients, 59.5% were male, with a median age of 43 years. The main etiologies were: inflammatory (23.7%), hereditary (18.9%), idiopathic (13.7%), multifactorial (11.1%), and diabetes (10.8%). The main electrophysiological patterns were axonal sensorimotor polyneuropathy (36.1%) and "demyelinating and axonal" sensorimotor polyneuropathy (27.9%). Axonal patterns showed greater etiological heterogeneity, with a predominance of idiopathic and multifactorial polyneuropathy, while demyelinating and "demyelinating and axonal" polyneuropathies had a significantly fewer etiologies, with a predominance of hereditary and inflammatory polyneuropathies. CONCLUSION The main causes of polyneuropathy confirmed by EDX test in this study were those that presented a severe, atypical and/or rapidly progressing pattern. Other causes were hereditary and those that defy clinical reasoning, such as multiple risk factors; some polyneuropathies did not have a specific etiology. EDX tests are useful for etiological diagnosis of rare polyneuropathies, because neurophysiological patterns are correlated with specific etiologies.
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Affiliation(s)
- Renata Dal-Prá Ducci
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Divisão de Neurologia, Serviço de Doenças Neuromusculares, Curitiba PR, Brazil
| | | | - Cláudia Suemi Kamoi Kay
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Divisão de Neurologia, Serviço de Doenças Neuromusculares, Curitiba PR, Brazil
| | - Otto Jesus Hernandez Fustes
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Divisão de Neurologia, Serviço de Doenças Neuromusculares, Curitiba PR, Brazil
| | - Lineu Cesar Werneck
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Divisão de Neurologia, Serviço de Doenças Neuromusculares, Curitiba PR, Brazil
| | - Paulo José Lorenzoni
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Divisão de Neurologia, Serviço de Doenças Neuromusculares, Curitiba PR, Brazil
| | - Rosana Herminia Scola
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Medicina Interna, Divisão de Neurologia, Serviço de Doenças Neuromusculares, Curitiba PR, Brazil
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Sensory-Motor Polyneuropathy and Digital Ischemia: A Rare Presentation of Granulomatosis with Polyangiitis. Case Rep Rheumatol 2021; 2021:5353575. [PMID: 34751236 PMCID: PMC8572124 DOI: 10.1155/2021/5353575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 09/27/2021] [Accepted: 10/16/2021] [Indexed: 11/17/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA) typically presents with upper or lower respiratory tract symptoms and/or with renal involvement. Although it can affect the peripheral nervous system frequently, with mononeuritis multiplex being the most common pattern, the occurrence of peripheral sensory-motor polyneuropathy as a presenting manifestation is distinctly rare. Prevalence of digital gangrene is also extremely rare in GPA. We describe a 46-year-old woman presenting with severe peripheral sensorimotor polyneuropathy affecting bilateral lower limbs preceded by a purpuric skin rash and multiple painful ulcers confined to the lower limbs. She had evidence of digital ischemia affecting multiple toes and dry gangrene of the left 4th toe. Diagnosis of GPA was made based on skin biopsy, positive ANCA serology, and clinical criteria. She made a good recovery following aggressive immunosuppressive treatment with methylprednisolone and cyclophosphamide and was maintained on prednisolone and azathioprine. This case highlights the importance of suspecting GPA in a patient presenting with sensorimotor polyneuropathy and/or digital ischemia even in the absence of more classic presenting features and underlies the necessity of accurate differential diagnosis in evaluating a case of peripheral neuropathy.
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Jin L, Liu Y. Clinical Manifestations, Pathogenesis, Diagnosis and Treatment of Peripheral Neuropathies in Connective Tissue Diseases: More Diverse and Frequent in Different Subtypes than Expected. Diagnostics (Basel) 2021; 11:diagnostics11111956. [PMID: 34829303 PMCID: PMC8618211 DOI: 10.3390/diagnostics11111956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/15/2021] [Accepted: 10/17/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose of review: To discuss and summarize recent findings in peripheral neuropathy (PN) related to connective tissue diseases (CTD) including its prevalence, clinical manifestations, pathogenesis, diagnosis and treatment. Recent findings: Although PN is a common complication in CTD and has been well studied, recent research has shown that PN is more diverse and frequent in different subtypes of CTD than was expected. The incidence of PN in Sjögren’s syndrome and rheumatoid arthritis (RA) varies according to different disease subtypes, and the pathogenesis of neuropathic pain in different subtypes of eosinophilic granulomatosis with polyangiitis (EGPA) may also differ. Neurogenic inflammation, autoantibody-mediated changes, ischemia of the vascular wall and metabolic mechanisms have been shown to contribute to the pathogenesis of PN in CTD. Moreover, allergic inflammation has been recently identified as a possible new mechanism producing peripheral neuropathic pain associated with MPO-ANCA negative EGPA patients. Glucocorticoids are routinely used to relieve pain caused by PN. However, these steroids may cause hyperalgesia, exacerbate neuropathic pain, and activate the early phase of pain induction and produce hyperalgesia. Recently, neuroactive steroids, such as progesterone, tetrahydroprogesterone and testosterone, have been shown to exert protective effects for several PN symptoms, and in particular neuropathic pain. Neuroactive steroids will be an interesting topic for future research into PN in CTD. Summary: It is essential for the diagnosis and treatment of PN in CTD to be updated. Timely diagnosis, appropriate treatments, and multidisciplinary care are essential to minimize morbidity and decrease the risk of permanent neurologic deficits. Further studies are needed to guide diagnosis and treatment.
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Affiliation(s)
| | - Yu Liu
- Correspondence: ; Tel.: +86-139-1671-8761
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Doherty L, Chaudhry V. Inpatient Diagnosis and Management of Neuromuscular Disorders. Semin Neurol 2021; 41:493-510. [PMID: 34619777 DOI: 10.1055/s-0041-1733794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Although many neuromuscular conditions are evaluated on an outpatient basis owing to their chronic or progressive nature, more urgent evaluation and management is often required for the inpatient presenting with acute to subacute focal or generalized numbness or weakness. This review focuses on clinical pattern recognition and basic anatomic localization principles to aid in the identification of common, as well as some less frequently encountered, neuromuscular disorders in hospitalized patients. The characteristic clinical and diagnostic features, associated complications, and recommended treatments of key neuromuscular conditions with acute and subacute manifestations are discussed. These conditions can be life-threatening in some cases, such as in Guillain-Barré syndrome, owing to associated oropharyngeal weakness, respiratory failure, or marked dysautonomia. Prompt recognition of the clinical and pathologic features is therefore necessary to reduce associated morbidity and mortality.
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Affiliation(s)
- Leana Doherty
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vinay Chaudhry
- Department of Neurology, Division of Neuromuscular Medicine, University of North Carolina School of Medicine Chapel Hill, North Carolina
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Lima K, Tavee J, Dua A. Combination rituximab and intravenous immunoglobulin for treatment of refractory vasculitic neuropathy: a case series. Rheumatology (Oxford) 2021; 60:4884-4887. [PMID: 33502498 DOI: 10.1093/rheumatology/keab069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/04/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Limited evidence exists to guide treatment of refractory vasculitic neuropathy. While rituximab (RTX) and IVIG have both been proposed as individual treatment options for these patients, combination therapy has never been reported. METHODS Written informed consent was obtained from three patients with refractory vasculitic neuropathy who were treated with combination RTX and IVIG. Their electronic medical records were reviewed and clinical and functional outcomes were reported. RESULTS Two male patients with non-systemic vasculitic neuropathy and one male patient with granulomatosis with polyangiitis were treated with combination RTX and IVIG therapy. All three patients demonstrated clinical improvement with at least partial functional recovery and a reduction in corticosteroid dose. This combination was generally well tolerated. CONCLUSIONS Combination RTX and IVIG therapy may be a safe and effective treatment option for patients with refractory vasculitic neuropathy. Further studies are needed to better characterize the risks and benefits of this combination.
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Affiliation(s)
- Kaitlin Lima
- Division of Rheumatology, Department of Medicine
| | - Jinny Tavee
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anisha Dua
- Division of Rheumatology, Department of Medicine
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Sommer C, Carroll AS, Koike H, Katsuno M, Ort N, Sobue G, Vucic S, Spies JM, Doppler K, Kiernan MC. Nerve biopsy in acquired neuropathies. J Peripher Nerv Syst 2021; 26 Suppl 2:S21-S41. [PMID: 34523188 DOI: 10.1111/jns.12464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 06/02/2021] [Accepted: 08/24/2021] [Indexed: 11/29/2022]
Abstract
A diagnosis of neuropathy can typically be determined through clinical assessment and focused investigation. With technological advances, including significant progress in genomics, the role of nerve biopsy has receded over recent years. However, making a specific and, in some cases, tissue-based diagnosis is essential across a wide array of potentially treatable acquired peripheral neuropathies. When laboratory investigations do not suggest a definitive diagnosis, nerve biopsy remains the final step to ascertain the etiology of the disease. The present review highlights the utility of nerve biopsy in confirming a diagnosis, while further illustrating the importance of a tissue-based diagnosis in relation to treatment strategies, particularly when linked to long-term immunosuppressive therapies.
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Affiliation(s)
- Claudia Sommer
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Antonia S Carroll
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia.,Westmead Clinical School, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Neurology and Neurophysiology, St Vincent's Hospital, The University of NSW, Sydney, New South Wales, Australia
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nora Ort
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Gen Sobue
- Brain and Mind Research Center, Nagoya University, Nagoya, Japan.,Aichi Medical University, Nagakute, Japan
| | - Steve Vucic
- Westmead Clinical School, The University of Sydney, Camperdown, New South Wales, Australia
| | - Judith M Spies
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Neurology, Royal Prince Alfred Hospital, The University of Sydney, Camperdown, New South Wales, Australia
| | - Kathrin Doppler
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Matthew C Kiernan
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Neurology, Royal Prince Alfred Hospital, The University of Sydney, Camperdown, New South Wales, Australia
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