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Podnar S. Ultrasonographic abnormalities in clinically unaffected nerves of patients with nonvasculitic motor and sensorimotor mononeuropathies. Muscle Nerve 2024. [PMID: 39056164 DOI: 10.1002/mus.28223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION/AIMS Diagnostic criteria for multifocal motor neuropathy (MMN) and multifocal acquired demyelinating sensorimotor neuropathy (MADSAM) require the involvement of at least two peripheral nerves. However, many patients with very similar features have clinical involvement of only a single peripheral nerve, which may preclude their correct diagnosis and treatment. The present study aimed to present a cohort of such patients and discuss the role of ultrasonography (US) in their diagnosis. METHODS Patients with nonvasculitic immune-mediated motor mononeuropathies (MM) and sensorimotor mononeuropathies (SMM) were recruited prospectively or identified from the electronic records. They were invited to comprehensive follow-up visits consisting of clinical examination, electrodiagnostic (EDx), and US studies. RESULTS Twenty-four patients (13 men) were studied (11 with MM). The characteristics of MM and SMM patients were very similar to MMN and MADSAM, respectively. The US, in addition to a long-swollen segment (average length, 20 cm) in the clinically affected nerve, revealed nerve swelling in, on average, six additional sites in clinically unaffected nerves. DISCUSSION In patients with clinical and EDx involvement of only a single nerve, an US demonstration of multifocal peripheral nerve swelling points to a more widespread, probably dysimmune mechanism. Further studies are needed to evaluate the value of US as a supplementary method for the diagnosis of MADSAM and MMN in patients with clinical involvement of a single nerve.
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Affiliation(s)
- Simon Podnar
- Division of Neurology, Institute of Clinical Neurophysiology, University Medical Center Ljubljana, Ljubljana, Slovenia
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2
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Al‐Zuhairy A, Jakobsen J, Krarup C. Prevention of axonal loss after immediate dosage titration of immunoglobulin in multifocal motor neuropathy. Eur J Neurol 2024; 31:e16305. [PMID: 38651498 PMCID: PMC11235608 DOI: 10.1111/ene.16305] [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: 11/21/2023] [Revised: 02/27/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND To evaluate whether ongoing axonal loss can be prevented in multifocal motor neuropathy (MMN) treated with immunoglobulin G (IgG), a group of patients with a median disease duration of 15.7 years (range: 8.3-37.8), treated with titrated dosages of immunoglobulins, was studied electrophysiologically at time of diagnosis and at follow-up. RESULTS At follow-up, the Z-score of the compound motor action potential amplitude of the median, fibular, and tibial nerves and the neurological performances were determined. In seven patients with a treatment-free period of 0.3 years (0.2-0.4), there was no progression of axonal loss (p = 0.2), whereas a trend toward further axonal loss by 1.3 Z-scores (0.9-17.0, p = 0.06) was observed in five patients with a treatment-free period of 4.0 years (0.9-9.0). The axonal loss in the group with a short treatment delay was significantly smaller than in the group with a longer treatment delay (p = 0.02). Also, there was an association between treatment delay and ongoing axonal loss (p = 0.004). The electrophysiological findings at follow-up were associated with the isokinetic strength performance, the neurological impairment score, and the disability, supporting the clinical relevance of the electrophysiological estimate of axonal loss. CONCLUSION Swift initiation of an immediately titrated IgG dosage can prevent further axonal loss and disability in continuously treated MMN patients.
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Affiliation(s)
- Ali Al‐Zuhairy
- Department of NeurologyCopenhagen University Hospital (Rigshospitalet)CopenhagenDenmark
| | - Johannes Jakobsen
- Department of NeurologyCopenhagen University Hospital (Rigshospitalet)CopenhagenDenmark
| | - Christian Krarup
- Department of Clinical NeurophysiologyRigshospitaletCopenhagenDenmark
- Department of NeuroscienceUniversity of CopenhagenCopenhagenDenmark
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3
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Martínez-Martínez L, Lacruz AC, Querol L, Cortés-Vicente E, Pascual E, Rojas-García R, Reyes-Leiva D, Álvaro Y, Moltó E, Ortiz E, Gallardo E, Juárez C, Mariscal A. Inter-laboratory comparison of routine autoantibody detection methods for autoimmune neuropathies and myasthenia gravis. J Neurol 2024; 271:4119-4130. [PMID: 38578496 DOI: 10.1007/s00415-024-12317-0] [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: 01/03/2024] [Revised: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 04/06/2024]
Abstract
Serological tests are important to detect autoantibodies (autoAbs) in patients with autoimmune neuropathies (AN) and myasthenia gravis (MG) as they are biomarkers for diagnosis, stratification, treatment selection, and monitoring. However, tests to detect autoAbs frequently lack proper standardization and results differ across diagnostic laboratories. We compared results for tests routinely performed in Spanish diagnostic laboratories to detect AN and MG autoAbs. In the Spanish Society of Immunology Autoimmunity Group national workshop, serum samples from 13 patients with AN or MG were tested for anti-ganglioside, anti-myelin-associated glycoprotein (MAG), anti-nicotinic acetylcholine receptor (AChR), and anti-muscle-specific kinase (MuSK) autoAbs using reference methods and were distributed for analysis to 27 participating laboratories using their routine methods. Overserved were inter-laboratory variability and worryingly low sensitivity, especially for anti-ganglioside immunoglobulin G and anti-MAG autoAb detection. This pilot study reflects autoAbs detection state of the art in AN and MG testing in leading diagnostic laboratories in Spain, highlighting the need for standardization prior to clinical use.
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Affiliation(s)
- Laura Martínez-Martínez
- Immunology Department, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Anna Calvet Lacruz
- Immunology Department, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Luis Querol
- Neurology Department, Neuromuscular Diseases Unit, Hospital de La Santa Creu I Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Neuromuscular Diseases Unit, Centre for Networked Biomedical Research in Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Cortés-Vicente
- Neurology Department, Neuromuscular Diseases Unit, Hospital de La Santa Creu I Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Neuromuscular Diseases Unit, Centre for Networked Biomedical Research in Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Elba Pascual
- Neurology Department, Neuromuscular Diseases Unit, Hospital de La Santa Creu I Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Neuromuscular Diseases Unit, Centre for Networked Biomedical Research in Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Ricard Rojas-García
- Neurology Department, Neuromuscular Diseases Unit, Hospital de La Santa Creu I Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Neuromuscular Diseases Unit, Centre for Networked Biomedical Research in Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - David Reyes-Leiva
- Neurology Department, Neuromuscular Diseases Unit, Hospital de La Santa Creu I Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Yolanda Álvaro
- Immunology Department, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Elisabeth Moltó
- Immunology Department, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Esther Ortiz
- Immunology Department, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Eduard Gallardo
- Neurology Department, Neuromuscular Diseases Unit, Hospital de La Santa Creu I Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Neuromuscular Diseases Unit, Centre for Networked Biomedical Research in Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Cándido Juárez
- Immunology Department, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
| | - Anaís Mariscal
- Immunology Department, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain.
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4
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Wohnrade C, Seeliger T, Gingele S, Bjelica B, Skripuletz T, Petri S. Diagnostic value of neurofilaments in differentiating motor neuron disease from multifocal motor neuropathy. J Neurol 2024; 271:4441-4452. [PMID: 38683209 PMCID: PMC11233354 DOI: 10.1007/s00415-024-12355-8] [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: 01/08/2024] [Revised: 03/23/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE To evaluate the performance of serum neurofilament light chain (NfL) and cerebrospinal fluid (CSF) phosphorylated neurofilament heavy chain (pNfH) as diagnostic biomarkers for the differentiation between motor neuron disease (MND) and multifocal motor neuropathy (MMN). METHODS This retrospective, monocentric study included 16 patients with MMN and 34 incident patients with MND. A subgroup of lower motor neuron (MN) dominant MND patients (n = 24) was analyzed separately. Serum NfL was measured using Ella automated immunoassay, and CSF pNfH was measured using enzyme-linked immunosorbent assay. Area under the curve (AUC), optimal cutoff values (Youden's index), and correlations with demographic characteristics were calculated. RESULTS Neurofilament concentrations were significantly higher in MND compared to MMN (p < 0.001), and serum NfL and CSF pNfH correlated strongly with each other (Spearman's rho 0.68, p < 0.001). Serum NfL (AUC 0.946, sensitivity and specificity 94%) and CSF pNfH (AUC 0.937, sensitivity 90.0%, specificity 100%) performed excellent in differentiating MND from MMN. Optimal cutoff values were ≥ 44.15 pg/mL (serum NfL) and ≥ 715.5 pg/mL (CSF pNfH), respectively. Similar results were found when restricting the MND cohort to lower MN dominant patients. Only one MMN patient had serum NfL above the cutoff. Two MND patients presented with neurofilament concentrations below the cutoffs, both featuring a slowly progressive disease. CONCLUSION Neurofilaments are valuable supportive biomarkers for the differentiation between MND and MMN. Serum NfL and CSF pNfH perform similarly well and elevated neurofilaments in case of diagnostic uncertainty underpin MND diagnosis.
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Affiliation(s)
- Camilla Wohnrade
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany.
| | - Tabea Seeliger
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Stefan Gingele
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Bogdan Bjelica
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, 30625, Hannover, Germany
- Center for Systems Neuroscience (ZSN) Hannover, 30559, Hannover, Germany
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5
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Kokubun N, Funakoshi K, Yuki N. Do corticosteroids aggravate pure motor chronic inflammatory demyelinating polyneuropathy? J Peripher Nerv Syst 2024; 29:286-287. [PMID: 38853616 DOI: 10.1111/jns.12639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 05/28/2024] [Indexed: 06/11/2024]
Affiliation(s)
- Norito Kokubun
- Department of Neurology, Dokkyo Medical University, Shimotsuga-gun, Tochigi, Japan
| | - Kei Funakoshi
- Department of Neurology, Dokkyo Medical University, Shimotsuga-gun, Tochigi, Japan
| | - Nobuhiro Yuki
- Department of Neurology, Takai Hospital, Tenri, Nara, Japan
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6
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van den Bergh PYK, van Doorn PA, Hadden RDM. Reply to the Letter to the Editor "Do corticosteroids aggravate pure motor chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)?" by Kokubun N. et al. J Peripher Nerv Syst 2024; 29:288-289. [PMID: 38873949 DOI: 10.1111/jns.12640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/15/2024]
Affiliation(s)
- P Y K van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | - P A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - R D M Hadden
- Department of Neurology, King's College Hospital, London, UK
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7
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Doneddu PE, Gentile L, Cocito D, Fazio R, Luigetti M, Briani C, Filosto M, Siciliano G, Benedetti L, Antonini G, Matà S, Marfia GA, Inghilleri M, Manganelli F, Cosentino G, Brighina F, Carpo M, Carta F, Mazzeo A, Peci E, Strano C, Romano A, Campagnolo M, Cotti‐Piccinelli S, Viola DV, Germano F, Leonardi L, Sperti M, Mataluni G, Ceccanti M, Spina E, Vegezzi E, Di Stefano V, Nobile‐Orazio E. Assessment of diagnostic criteria for multifocal motor neuropathy in patients included in the Italian database. Eur J Neurol 2024; 31:e16248. [PMID: 38376074 PMCID: PMC11235749 DOI: 10.1111/ene.16248] [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: 11/29/2023] [Revised: 01/18/2024] [Accepted: 01/30/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND PURPOSE This study aimed to assess the diagnostic criteria, ancillary investigations and treatment response using real-life data in multifocal motor neuropathy (MMN) patients. METHODS Clinical and laboratory data were collected from 110 patients enrolled in the Italian MMN database through a structured questionnaire. Twenty-six patients were excluded due to the unavailability of nerve conduction studies or the presence of clinical signs and symptoms and electrodiagnostic abnormalities inconsistent with the MMN diagnosis. Analyses were conducted on 73 patients with a confirmed MMN diagnosis and 11 patients who did not meet the diagnostic criteria. RESULTS The European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) diagnostic criteria were variably applied. AUTHOR When applying the American Association of Electrodiagnostic Medicine criteria, an additional 17% of patients fulfilled the criteria for probable/definite diagnosis whilst a further 9.5% missed the diagnosis. In 17% of the patients only compound muscle action potential amplitude, but not area, was measured and subsequently recorded in the database by the treating physician. Additional investigations, including anti-GM1 immunoglobulin M antibodies, cerebrospinal fluid analysis, nerve ultrasound and magnetic resonance imaging, supported the diagnosis in 46%-83% of the patients. Anti-GM1 immunoglobulin M antibodies and nerve ultrasound demonstrated the highest sensitivity. Additional tests were frequently performed outside the EFNS/PNS guideline recommendations. CONCLUSIONS This study provides insights into the real-world diagnostic and management strategies for MMN, highlighting the challenges in applying diagnostic criteria.
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Affiliation(s)
- Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology UnitIRCCS Humanitas Research HospitalRozzanoItaly
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleItaly
| | - Luca Gentile
- Department of Clinical and Experimental Medicine, Unit of NeurologyUniversity of MessinaMessinaItaly
| | - Dario Cocito
- Department of Clinical and Biological SciencesUniversity of TorinoTorinoItaly
| | - Raffaella Fazio
- Division of Neuroscience, Department of NeurologyInstitute of Experimental Neurology (INSPE), San Raffaele Scientific InstituteMilanoItaly
| | - Marco Luigetti
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC NeurologiaRomaItaly
- Università Cattolica del Sacro Cuore, Sede di RomaRomaItaly
| | - Chiara Briani
- Neurology Unit, Department of NeuroscienceUniversity of PadovaPadovaItaly
| | - Massimiliano Filosto
- Department of Clinical and Experimental SciencesUniversity of Brescia; NeMO‐Brescia Clinical center for Neuromuscular DiseasesBresciaItaly
| | - Gabriele Siciliano
- Neurology Unit, Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | | | - Giovanni Antonini
- Unit of Neurophysiopathology, Department of Neurology Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sant'Andrea HospitalSapienza' University of RomeRomaItaly
| | - Sabrina Matà
- Department of Neurological and Psychiatric SciencesAzienda Ospedaliero‐Universitaria di CareggiFlorenceItaly
| | | | - Maurizio Inghilleri
- Department of Human NeurosciencesSapienza University of RomeRomeItaly
- IRCCS NeuromedPozzilliItaly
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive Sciences and OdontostomatologyUniversity of Naples 'Federico II'NapoliItaly
| | - Giuseppe Cosentino
- Department of Brain and Behavioral Sciences, IRCCS Mondino FoundationUniversity of PaviaPaviaItaly
| | - Filippo Brighina
- Azienda Ospedaliera Universitaria Policlinico Paolo GiacconePalermoItaly
| | | | - Francesca Carta
- Neuromuscular and Neuroimmunology UnitIRCCS Humanitas Research HospitalRozzanoItaly
| | - Anna Mazzeo
- Department of Clinical and Experimental Medicine, Unit of NeurologyUniversity of MessinaMessinaItaly
| | - Erdita Peci
- Presidio Sanitario Major, Istituti Clinici Scientifici MaugeriTorinoItaly
| | - Camilla Strano
- Division of Neuroscience, Department of NeurologyInstitute of Experimental Neurology (INSPE), San Raffaele Scientific InstituteMilanoItaly
| | - Angela Romano
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC NeurologiaRomaItaly
- Università Cattolica del Sacro Cuore, Sede di RomaRomaItaly
| | - Marta Campagnolo
- Neurology Unit, Department of NeuroscienceUniversity of PadovaPadovaItaly
| | - Stefano Cotti‐Piccinelli
- Department of Clinical and Experimental SciencesUniversity of Brescia; NeMO‐Brescia Clinical center for Neuromuscular DiseasesBresciaItaly
| | - Divina Valeria Viola
- Neurology Unit, Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | | | - Luca Leonardi
- Unit of Neurophysiopathology, Department of Neurology Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sant'Andrea HospitalSapienza' University of RomeRomaItaly
| | - Martina Sperti
- Department of Neurological and Psychiatric SciencesAzienda Ospedaliero‐Universitaria di CareggiFlorenceItaly
| | - Giorgia Mataluni
- Dysimmune Neuropathies Unit, Department of Systems MedicineTor Vergata University of RomeRomaItaly
| | - Marco Ceccanti
- Department of Human NeurosciencesSapienza University of RomeRomeItaly
| | - Emanuele Spina
- Department of Neuroscience, Reproductive Sciences and OdontostomatologyUniversity of Naples 'Federico II'NapoliItaly
| | - Elisa Vegezzi
- Department of Brain and Behavioral Sciences, IRCCS Mondino FoundationUniversity of PaviaPaviaItaly
| | | | - Eduardo Nobile‐Orazio
- Neuromuscular and Neuroimmunology UnitIRCCS Humanitas Research HospitalRozzanoItaly
- Department of Medical Biotechnology and Translational MedicineMilan UniversityMilanoItaly
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8
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Budding K, Bos JW, Dijkxhoorn K, de Zeeuw E, Bloemenkamp LM, Zekveld EM, Groen EJN, Jacobs BC, Huizinga R, Goedee HS, Cats EA, Leusen JHW, van den Berg LH, Hack CE, van der Pol WL. IgM anti-GM2 antibodies in patients with multifocal motor neuropathy target Schwann cells and are associated with early onset. J Neuroinflammation 2024; 21:100. [PMID: 38632654 PMCID: PMC11025174 DOI: 10.1186/s12974-024-03090-y] [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: 02/02/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Multifocal motor neuropathy (MMN) is a rare, chronic immune-mediated polyneuropathy characterized by asymmetric distal limb weakness. An important feature of MMN is the presence of IgM antibodies against gangliosides, in particular GM1 and less often GM2. Antibodies against GM1 bind to motor neurons (MNs) and cause damage through complement activation. The involvement of Schwann cells (SCs), expressing GM1 and GM2, in the pathogenesis of MMN is unknown. METHODS Combining the data of our 2007 and 2015 combined cross-sectional and follow-up studies in Dutch patients with MMN, we evaluated the presence of IgM antibodies against GM1 and GM2 in serum from 124 patients with MMN and investigated their binding to SCs and complement-activating properties. We also assessed the relation of IgM binding and complement deposition with clinical characteristics. RESULTS Thirteen out of 124 patients (10%) had a positive ELISA titer for IgM anti-GM2. Age at onset of symptoms was significantly lower in MMN patients with anti-GM2 IgM. IgM binding to SCs correlated with IgM anti-GM2 titers. We found no correlation between IgM anti-GM2 titers and MN binding or with IgM anti-GM1 titers. IgM binding to SCs decreased upon pre-incubation of serum with soluble GM2, but not with soluble GM1. IgM anti-GM2 binding to SCs correlated with complement activation, as reflected by increased C3 fixation on SCs and C5a formation in the supernatant. CONCLUSION Circulating IgM anti-GM2 antibodies define a subgroup of patients with MMN that has an earlier onset of disease. These antibodies probably target SCs specifically and activate complement, similarly as IgM anti-GM1 on MNs. Our data indicate that complement activation by IgM antibodies bound to SCs and MNs underlies MMN pathology.
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Affiliation(s)
- Kevin Budding
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen W Bos
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Kim Dijkxhoorn
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Elisabeth de Zeeuw
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lauri M Bloemenkamp
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Eva M Zekveld
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ewout J N Groen
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Bart C Jacobs
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ruth Huizinga
- Department of Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Elisabeth A Cats
- Department of Neurology, Gelre Hospital, Apeldoorn, The Netherlands
| | - Jeanette H W Leusen
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - C Erik Hack
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W Ludo van der Pol
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands.
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9
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De Lorenzo A, Liberatore G, Doneddu PE, Manganelli F, Cocito D, Briani C, Fazio R, Mazzeo A, Schenone A, Di Stefano V, Cosentino G, Marfia GA, Benedetti L, Carpo M, Filosto M, Antonini G, Clerici AM, Luigetti M, Matà S, Rosso T, Lucchetta M, Siciliano G, Lauria Pinter G, Cavaletti G, Inghilleri M, Cantisani T, Notturno F, Ricciardi D, Habetswallner F, Spina E, Peci E, Salvalaggio A, Falzone Y, Strano C, Gentile L, Vegezzi E, Mataluni G, Cotti Piccinelli S, Leonardi L, Romano A, Nobile‐Orazio E. Impact of 2021 European Academy of Neurology/Peripheral Nerve Society diagnostic criteria on diagnosis and therapy of chronic inflammatory demyelinating polyradiculoneuropathy variants. Eur J Neurol 2024; 31:e16190. [PMID: 38165011 PMCID: PMC11235819 DOI: 10.1111/ene.16190] [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: 08/10/2023] [Revised: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND PURPOSE There are different criteria for the diagnosis of different variants of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). The 2021 European Academy of Neurology/Peripheral Nerve Society (EAN/PNS) guidelines provide specific clinical criteria for each CIDP variant even if their therapeutical impact has not been investigated. METHODS We applied the clinical criteria for CIDP variants of the 2021 EAN/PNS guidelines to 369 patients included in the Italian CIDP database who fulfilled the 2021 EAN/PNS electrodiagnostic criteria for CIDP. RESULTS According to the 2021 EAN/PNS clinical criteria, 245 patients achieved a clinical diagnosis of typical CIDP or CIDP variant (66%). We identified 106 patients with typical CIDP (29%), 62 distal CIDP (17%), 28 multifocal or focal CIDP (7%), four sensory CIDP (1%), 27 sensory-predominant CIDP (7%), 10 motor CIDP (3%), and eight motor-predominant CIDP (2%). Patients with multifocal, distal, and sensory CIDP had milder impairment and symptoms. Patients with multifocal CIDP had less frequently reduced conduction velocity and prolonged F-wave latency and had lower levels of cerebrospinal fluid protein. Patients with distal CIDP more frequently had reduced distal compound muscle action potentials. Patients with motor CIDP did not improve after steroid therapy, whereas those with motor-predominant CIDP did. None of the patients with sensory CIDP responded to steroids, whereas most of those with sensory-predominant CIDP did. CONCLUSIONS The 2021 EAN/PNS criteria for CIDP allow a better characterization of CIDP variants, permitting their distinction from typical CIDP and more appropriate treatment for patients.
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Affiliation(s)
- Alberto De Lorenzo
- Neuromuscular and Neuroimmunology UnitIRCCS Humanitas Research HospitalMilanItaly
| | - Giuseppe Liberatore
- Neuromuscular and Neuroimmunology UnitIRCCS Humanitas Research HospitalMilanItaly
| | - Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology UnitIRCCS Humanitas Research HospitalMilanItaly
- Department of Biomedical SciencesHumanitas UniversityMilanItaly
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive Sciences, and OdontostomatologyUniversity of Naples "Federico II"NaplesItaly
| | - Dario Cocito
- Department of NeuroscienceUniversity of TurinTurinItaly
| | - Chiara Briani
- Neurology Unit, Department of NeuroscienceUniversity of PaduaPaduaItaly
| | - Raffaella Fazio
- Division of Neuroscience, Department of Neurology, Institute of Experimental NeurologySan Raffaele Scientific InstituteMilanItaly
| | - Anna Mazzeo
- Department of Clinical and Experimental Medicine, Unit of NeurologyUniversity of MessinaMessinaItaly
| | - Angelo Schenone
- Neurology ClinicIRCCS Ospedale Policlinico San Martino GenovaGenoaItaly
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child HealthUniversity of Genoa and IRCCS AOU San Martino‐ISTGenoaItaly
| | - Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience, and Advanced DiagnosticsUniversity of PalermoPalermoItaly
| | - Giuseppe Cosentino
- Department of Brain and Behavioral SciencesUniversity of PaviaPaviaItaly
- IRCCS Mondino FoundationPaviaItaly
| | | | - Luana Benedetti
- Neurology ClinicIRCCS Ospedale Policlinico San Martino GenovaGenoaItaly
| | - Marinella Carpo
- Department of NeurologyASST Bergamo Ovest‐Ospedale TreviglioTreviglioItaly
| | - Massimiliano Filosto
- Center for Neuromuscular Diseases and Neuropathies, Unit of Neurology, ASST "Spedali Civili"University of BresciaBresciaItaly
| | - Giovanni Antonini
- Unit of Neuromuscular Diseases, Department of Neurology Mental Health and Sensory Organs, Faculty of Medicine and Psychology"Sapienza" University of Rome, Sant'Andrea HospitalRomeItaly
| | | | - Marco Luigetti
- Neurology Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCSUniversità Cattolica del Sacro CuoreRomeItaly
| | - Sabrina Matà
- Neurology Unit, Dipartimento Neuromuscoloscheletrico e Degli Organi di SensoUniversity Hospital CareggiFlorenceItaly
| | | | - Marta Lucchetta
- UOC Neurologia, Ospedale Santa Maria della MisericordiaRovigoItaly
| | - Gabriele Siciliano
- Neurology Unit, Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | - Giuseppe Lauria Pinter
- Unit of NeuroalgologyIRCCS Foundation "Carlo Besta" Neurological InstituteMilanItaly
- Department of Medical Biotechnology and Translational MedicineMilan UniversityMilanItaly
| | - Guido Cavaletti
- School of Medicine and Surgery and Experimental Neurology UnitUniversity of Milano‐BicoccaMonzaItaly
| | - Maurizio Inghilleri
- Neurodegenerative Diseases Unit, Department of Human NeuroscienceSapienza University, Policlinico Universitario Umberto IRomeItaly
| | - Teresa Cantisani
- Servizio di NeurofisiopatologiaAzienda Ospedaliera di PerugiaPerugiaItaly
| | | | - Dario Ricciardi
- Division of Neurology and Neurophysiopathology, Department of Medical and Surgical SciencesUniversity of Campania "Luigi Vanvitelli"NaplesItaly
- Clinical Neurophysiology UnitCardarelli HospitalNaplesItaly
| | | | - Emanuele Spina
- Department of Neuroscience, Reproductive Sciences, and OdontostomatologyUniversity of Naples "Federico II"NaplesItaly
| | - Erdita Peci
- Department of NeuroscienceUniversity of TurinTurinItaly
| | | | - Yuri Falzone
- Division of Neuroscience, Department of Neurology, Institute of Experimental NeurologySan Raffaele Scientific InstituteMilanItaly
| | - Camilla Strano
- Division of Neuroscience, Department of Neurology, Institute of Experimental NeurologySan Raffaele Scientific InstituteMilanItaly
| | - Luca Gentile
- Department of Clinical and Experimental Medicine, Unit of NeurologyUniversity of MessinaMessinaItaly
| | | | - Giorgia Mataluni
- Dysimmune Neuropathies Unit, Department of Systems MedicineTor Vergata University of RomeRomeItaly
| | - Stefano Cotti Piccinelli
- Center for Neuromuscular Diseases and Neuropathies, Unit of Neurology, ASST "Spedali Civili"University of BresciaBresciaItaly
| | - Luca Leonardi
- Unit of Neuromuscular Diseases, Department of Neurology Mental Health and Sensory Organs, Faculty of Medicine and Psychology"Sapienza" University of Rome, Sant'Andrea HospitalRomeItaly
| | - Angela Romano
- Neurology Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCSUniversità Cattolica del Sacro CuoreRomeItaly
| | - Eduardo Nobile‐Orazio
- Neuromuscular and Neuroimmunology UnitIRCCS Humanitas Research HospitalMilanItaly
- Department of Medical Biotechnology and Translational MedicineMilan UniversityMilanItaly
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10
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Zhang L, Li Y, Niu J, Hu N, Ding J, Cui L, Liu M. Neuromuscular ultrasound in combination with nerve conduction studies helps identify inflammatory motor neuropathies from lower motor neuron syndromes. Eur J Neurol 2024; 31:e16202. [PMID: 38235844 PMCID: PMC11235880 DOI: 10.1111/ene.16202] [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: 07/06/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND PURPOSE Identifying patients with inflammatory motor neuropathies (IMNs) is warranted since effective treatments are available and the prognosis of these patients differs from that of amyotrophic lateral sclerosis patients. METHODS Between January 2019 and May 2022, 102 consecutive treatment-naïve lower motor neuron syndrome (LMNS) patients were recruited; these patients were suspected of having multifocal motor neuropathy, pure motor chronic inflammatory demyelinating polyneuropathy or amyotrophic lateral sclerosis with initial lower motor neuron presentation. Neuromuscular ultrasound (US) and nerve conduction studies (NCSs) were conducted at baseline. Relevant diagnostic investigations were performed if clinically warranted. The proposed US evidence of IMN was as follows: (i) nerve enlargement at ≥1 of the predetermined sites or (ii) absence of high intensity fasciculations in predefined muscle groups. Final diagnoses were made by experienced physicians after a prolonged follow-up period (≥12 months). IMN patients were defined as LMNS patients who experienced convincing improvements in response to immunotherapies. IMN patients without electrodiagnostic demyelinating features were diagnosed with treatment-responsive LMNS (TR-LMNS). RESULTS In total, 16 patients were classified as IMN, including nine chronic inflammatory demyelinating polyneuropathy/multifocal motor neuropathy patients and seven TR-LMNS patients. Six TR-LMNS patients were identified by neuromuscular US. The sensitivity and specificity of NCSs, nerve US and muscle US were 56.3% and 100%, 43.8% and 90.7% and 68.8% and 97.7%, respectively. When these three modalities were combined, the sensitivity and specificity were 93.8% and 88.4%, respectively. CONCLUSION Neuromuscular US studies are supplementary modalities to NCSs, and the combined use of these techniques might improve the identification of IMNs in LMNS patients.
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Affiliation(s)
- Lei Zhang
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Yi Li
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Jingwen Niu
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Nan Hu
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Jianfeng Ding
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Liying Cui
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Mingsheng Liu
- Department of Neurology, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
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11
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Allen JA, Clarke AE, Harbo T. A Practical Guide to Identify Patients With Multifocal Motor Neuropathy, a Treatable Immune-Mediated Neuropathy. Mayo Clin Proc Innov Qual Outcomes 2024; 8:74-81. [PMID: 38283096 PMCID: PMC10819864 DOI: 10.1016/j.mayocpiqo.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
Multifocal motor neuropathy (MMN) is a rare immune-mediated motor neuropathy characterized by asymmetric weakness that preferentially affects distal upper limb muscles. The clinical features of MMN may be difficult to differentiate from motor neuron disease. Other conditions that may be mistaken for MMN include inclusion body myositis, chronic inflammatory demyelinating polyradiculoneuropathy, hereditary neuropathy with liability to pressure palsy, focal neuropathies, and radiculopathies. A key distinguishing electrophysiologic feature of MMN is the motor nerve conduction block located at noncompressible sites. MMN is a treatable neuropathy; therefore it is important that primary care physicians are aware of the features of the disease to identify potential patients and make referrals to a neuromuscular specialist in a timely manner. This review provides an overview of the disease, highlights key differential diagnoses, and describes available treatment options for patients with MMN.
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Affiliation(s)
- Jeffrey A. Allen
- Department of Neurology, University of Minnesota, Minneapolis, MN
| | | | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, DK
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12
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Seeliger T, Gingele S, Güzeloglu YE, Heitmann L, Lüling B, Kohle F, Preßler H, Stascheit F, Motte J, Fisse AL, Grüter T, Pitarokoili K, Skripuletz T. Comparative analysis of albumin quotient and total CSF protein in immune-mediated neuropathies: a multicenter study on diagnostic implications. Front Neurol 2024; 14:1330484. [PMID: 38264088 PMCID: PMC10803547 DOI: 10.3389/fneur.2023.1330484] [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: 10/31/2023] [Accepted: 12/26/2023] [Indexed: 01/25/2024] Open
Abstract
Introduction Blood-cerebrospinal fluid (CSF) barrier dysfunction is pivotal for diagnosing immune-mediated neuropathies, especially in spinal nerve root inflammation. Typically, either total CSF protein or the CSF to serum albumin ratio (QAlb) is measured. Total CSF protein measurements have limitations, notably its fixed reference value regardless of age, in contrast to the age-dependent reference for QAlb. Our goal was to evaluate both markers in patients with immune-mediated neuropathies. Methods In our multicenter research, we collected retrospective CSF data from patients suffering from immune-mediated neuropathies across four German research centers. These parameters were analyzed in relation to their clinical characteristics. Results Out of 419 samples, 36 (8.6%) displayed a notable variation between total CSF protein and QAlb values. A detailed analysis revealed that patients displaying elevated QAlb but normal total CSF protein levels were significantly younger at disease onset (p = 0.01), at the time of diagnosis (p = 0.005), and when undergoing lumbar puncture (p = 0.001) compared to patients with elevated CSF protein and normal QAlb levels. These effects were especially evident for the subgroup of samples derived by female patients. Discussion Our work confirms the crucial role of QAlb in diagnosing immune-mediated neuropathies and particularly its efficacy as a marker for evaluating the blood-CSF barrier in patients with an earlier disease onset. Considering the significance of the albumin quotient, its assessment is especially advisable in younger patients of female sex to avoid missing a potential barrier dysfunction that might be falsely negative when using total protein.
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Affiliation(s)
- Tabea Seeliger
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Stefan Gingele
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Lena Heitmann
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Benjamin Lüling
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Felix Kohle
- Department of Neurology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Hannah Preßler
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität, Berlin, Germany
- Neuroscience Clinical Research Center, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Frauke Stascheit
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität, Berlin, Germany
- Neuroscience Clinical Research Center, Charité — Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jeremias Motte
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Anna Lena Fisse
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Thomas Grüter
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Kalliopi Pitarokoili
- Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany
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Telleman JA, Sneag DB, Visser LH. The role of imaging in focal neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:19-42. [PMID: 38697740 DOI: 10.1016/b978-0-323-90108-6.00001-6] [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: 05/05/2024]
Abstract
Electrodiagnostic testing (EDX) has been the diagnostic tool of choice in peripheral nerve disease for many years, but in recent years, peripheral nerve imaging has been used ever more frequently in daily clinical practice. Nerve ultrasound and magnetic resonance (MR) neurography are able to visualize nerve structures reliably. These techniques can aid in localizing nerve pathology and can reveal significant anatomical abnormalities underlying nerve pathology that may have been otherwise undetected by EDX. As such, nerve ultrasound and MR neurography can significantly improve diagnostic accuracy and can have a significant effect on treatment strategy. In this chapter, the basic principles and recent developments of these techniques will be discussed, as well as their potential application in several types of peripheral nerve disease, such as carpal tunnel syndrome (CTS), ulnar neuropathy at the elbow (UNE), radial neuropathy, brachial and lumbosacral plexopathy, neuralgic amyotrophy (NA), fibular, tibial, sciatic, femoral neuropathy, meralgia paresthetica, peripheral nerve trauma, tumors, and inflammatory neuropathies.
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Affiliation(s)
- Johan A Telleman
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, United States
| | - Leo H Visser
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.
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14
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Tsoumanis P, Kitsouli A, Stefanou C, Papathanakos G, Stefanou S, Tepelenis K, Zikidis H, Tsoumani A, Zafeiropoulos P, Kitsoulis P, Kanavaros P. Chronic Inflammatory Demyelinating Polyneuropathy and Evaluation of the Visual Evoked Potentials: A Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2160. [PMID: 38138263 PMCID: PMC10744621 DOI: 10.3390/medicina59122160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/02/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rare autoimmune disorder characterised by the progressive demyelination of peripheral nerves, resulting in motor and sensory deficits. While much research has focused on clinical and electrophysiological aspects of CIDP, there is an emerging interest in exploring its impact on the visual system through visual evoked potentials (VEPs). This comprehensive review synthesises existing literature on VEP findings in CIDP patients, shedding light on their potential diagnostic and prognostic value. The review thoroughly examines studies spanning the last two decades, exploring VEP abnormalities in CIDP patients. Notably, VEP studies have consistently revealed prolonged latencies and reduced amplitudes in CIDP patients compared to healthy controls. These alterations in VEP parameters suggest that the demyelinating process extends beyond the peripheral nervous system to affect the central nervous system, particularly the optic nerve and its connections. The correlation between VEP abnormalities and clinical manifestations of CIDP, such as visual impairment and sensory deficits, underscores the clinical relevance of VEP assessment in CIDP management. Furthermore, this review addresses the potential utility of VEPs in aiding CIDP diagnosis and monitoring disease progression. VEP abnormalities may serve as valuable biomarkers for disease activity, helping clinicians make timely therapeutic decisions. Moreover, this review discusses the limitations and challenges associated with VEP assessment in CIDP, including variability in recording techniques and the need for standardised protocols. In conclusion, this review highlights the evolving role of VEPs as a non-invasive tool in CIDP evaluation. The consistent VEP abnormalities observed in CIDP patients suggest the involvement of the central nervous system in this demyelinating disorder. As our understanding of CIDP and its pathophysiology continues to evolve, further research in this area may lead to improved diagnostic accuracy and monitoring strategies, ultimately enhancing the clinical management of CIDP patients.
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Affiliation(s)
- Periklis Tsoumanis
- Department of Ophthalmology, University Hospital of Ioannina, 45500 Ioannina, Greece;
| | - Aikaterini Kitsouli
- Anatomy-Histology-Embryology, University of Ioannina, 45500 Ioannina, Greece; (A.K.); (P.K.); (P.K.)
| | - Christos Stefanou
- Department of Surgery, General Hospital of Filiates, 46300 Filiates, Greece;
| | | | - Stefanos Stefanou
- Department of Endocrine Surgery, Henry Dunant Hospital Center, 11526 Athens, Greece;
| | - Kostas Tepelenis
- Department of Surgery, General Hospital of Ioannina G. Hatzikosta, 45500 Ioannina, Greece;
| | - Hercules Zikidis
- Department of Neurology, University Hospital of Ioannina, 45500 Ioannina, Greece;
| | | | | | - Panagiotis Kitsoulis
- Anatomy-Histology-Embryology, University of Ioannina, 45500 Ioannina, Greece; (A.K.); (P.K.); (P.K.)
| | - Panagiotis Kanavaros
- Anatomy-Histology-Embryology, University of Ioannina, 45500 Ioannina, Greece; (A.K.); (P.K.); (P.K.)
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15
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Ogata H. [The significance of autoantibodies against nodal and paranodal proteins in autoimmune nodopathies]. Rinsho Shinkeigaku 2023; 63:715-724. [PMID: 37880115 DOI: 10.5692/clinicalneurol.cn-001878] [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: 10/27/2023]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is recognized as a syndrome caused by multiple pathologies. Since the 2010s, it has been clarified that autoantibodies against membranous proteins localized in the nodes of Ranvier and paranodes are positive in subsets of CIDP patients, leading to proposing a new disease concept called autoimmune nodopathies, which is independent of CIDP, in the revised international CIDP guidelines. This article reviews the significance of these autoantibodies, especially anti-neurofascin 155 and anti-contactin 1 antibodies, which have been the most prevalent and achieved a higher degree of consensus.
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16
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Kmezic I, Gustafsson R, Fink K, Svenningsson A, Samuelsson K, Ingre C, Olsson T, Hansson M, Kockum I, Adzemovic MZ, Press R. Validation of elevated levels of interleukin-8 in the cerebrospinal fluid, and discovery of new biomarkers in patients with GBS and CIDP using a proximity extension assay. Front Immunol 2023; 14:1241199. [PMID: 38077366 PMCID: PMC10702497 DOI: 10.3389/fimmu.2023.1241199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/01/2023] [Indexed: 12/18/2023] Open
Abstract
Background Biomarkers for diagnosis of inflammatory neuropathies, assessment of prognosis, and treatment response are lacking. Methods CSF and EDTA plasma from patients with Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), healthy controls (HC) and disease controls were analyzed with Olink multiplex proximity extension assay (PEA) from two independent cohorts. Levels of interleukin-8 (IL8) were further analyzed with ELISA in patients with GBS, CIDP, paraproteinemia-related demyelinating polyneuropathy (PDN), multifocal motor neuropathy (MMN), HC and disease controls. ROC analysis was performed. Outcome was measured with the GBS-disability score (GBS-ds) or Inflammatory Neuropathy Cause and Treatment (INCAT) score. Results In CSF, multiplex PEA analysis revealed up-regulation of IL8 in GBS compared to CIDP and HC respectively, and CIDP compared to HC. In addition, levels of IL2RA were upregulated in GBS compared to both HC and CIDP, SELE in GBS compared to HC, and ITGAM, IL6, and NRP1 in GBS compared to CIDP. In plasma, levels of MMP3, THBD and ITGAM were upregulated in CIDP compared to HC. Validation of multiplex IL8 results using ELISA, revealed increased levels of IL8 in CSF in patients with GBS and CIDP versus HC and non-inflammatory polyneuropathies (NIP) respectively, as well as in PDN versus NIP and HC. Levels of IL8 in CSF correlated with impairment in the acute phase of GBS as well as outcome at 6-months follow up. Conclusion IL8 in CSF is validated as a diagnostic biomarker in GBS and CIDP, and a prognostic biomarker in GBS. Multiplex PEA hereby identifies several potential biomarkers in GBS and CIDP.
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Affiliation(s)
- Ivan Kmezic
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rasmus Gustafsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Katharina Fink
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anders Svenningsson
- Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden
| | - Kristin Samuelsson
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Caroline Ingre
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Hansson
- Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
- Department of Laboratory Medicine H5, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Kockum
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Milena Z. Adzemovic
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Neurology, Academic Specialist Centre, Stockholm Health Services, Stockholm, Sweden
| | - Rayomand Press
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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17
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Yoshikawa M, Sekiguchi K, Suehiro H, Watanabe S, Noda Y, Hara H, Matsumoto R. Nerve enlargement differs among chronic inflammatory demyelinating polyradiculoneuropathy subtypes and multifocal motor neuropathy. Clin Neurophysiol Pract 2023; 8:228-234. [PMID: 38152246 PMCID: PMC10751816 DOI: 10.1016/j.cnp.2023.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/06/2023] [Accepted: 10/22/2023] [Indexed: 12/29/2023] Open
Abstract
Objective We aimed to evaluate differences in ultrasonographic nerve enlargement sites among typical chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), distal CIDP, multifocal CIDP and multifocal motor neuropathy (MMN) in a Japanese population. Methods We retrospectively reviewed medical records and selected 39 patients (14 with typical CIDP, 7 with multifocal CIDP, 4 with distal CIDP, and 14 with MMN) who underwent ultrasonography. Median and ulnar nerve cross-sectional areas (CSAs) were measured at the wrist, forearm, elbow, and upper arm. CSA ratios for each nerve were calculated as: wrist-to-forearm index (WFI) = wrist CSA/forearm CSA; elbow-to-upper arm index (EUI) = elbow CSA/upper arm CSA; and intranerve CSA variability (INCV) = maximal CSA/minimal CSA. Results Significant differences were observed among typical CIDP, multifocal CIDP, distal CIDP, and MMN in CSA at the forearm and upper arm in the median nerves (p < 0.05). Patients with multifocal CIDP had lower WFI and EUI and higher INCV than the other groups (p < 0.05). Conclusions Regardless of the untreated period, compared with other CIDP subtypes and MMN, multifocal CIDP showed a focal and marked nerve enlargement in the Japanese population. Significance Differences in nerve enlargement site may be an underlying feature of multifocal CIDP.
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Affiliation(s)
- Masaaki Yoshikawa
- Division of Neurology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima-cho, Saga 849-8501, Japan
| | - Kenji Sekiguchi
- Division of Neurology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan
| | - Hirotomo Suehiro
- Division of Neurology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan
| | - Shunsuke Watanabe
- Division of Neurology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan
| | - Yoshikatsu Noda
- Division of Neurology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima-cho, Saga 849-8501, Japan
- Fukuoka International University of Health and Welfare, 3-6-40 Momochihama, Sawara-ku, Fukuoka 814-0001, Japan
| | - Riki Matsumoto
- Division of Neurology, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo 650-0017, Japan
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Gable K. Chronic Immune-Mediated Demyelinating Neuropathies. Continuum (Minneap Minn) 2023; 29:1357-1377. [PMID: 37851034 DOI: 10.1212/con.0000000000001290] [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 is an overview of chronic demyelinating neuropathies and highlights the phenotypic categorization, diagnosis, and treatment of chronic immune-mediated neuropathies. The clinical and diagnostic characteristics of other chronic demyelinating neuropathies that are common mimics of immune-mediated neuropathies are also discussed. LATEST DEVELOPMENTS The underlying pathophysiology of chronic demyelinating neuropathies is heterogeneous, and components of both humoral and cellular immune responses are thought to play a role in the immune-mediated types of chronic demyelinating neuropathy. The role of the humoral response is highlighted with a specific focus on the relatively recent discovery of antibody-mediated antinodal and paranodal demyelinating neuropathies. Additionally, new diagnostic criteria for some of the chronic demyelinating neuropathies, as well as ways to differentiate chronic inflammatory demyelinating polyradiculoneuropathy from other chronic demyelinating polyneuropathies, are discussed. ESSENTIAL POINTS Chronic demyelinating neuropathies can present with overlapping clinical characteristics with seemingly subtle variations. It is clinically important to differentiate these types of neuropathies because the treatment and management can vary and affect prognosis.
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Di Egidio M, Bacaglio CR, Arrejoría R, Villa AM, Nores GA, Lopez PHH. Evidence for spontaneous regulation of the humoral IgM anti-GM1 autoimmune response by IgG antibodies in multifocal motor neuropathy patients. J Peripher Nerv Syst 2023; 28:398-406. [PMID: 37498737 DOI: 10.1111/jns.12583] [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: 03/10/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND AND AIMS Multifocal motor neuropathy (MMN) is a peripheral nerve disorder characterized by slow progressive distal asymmetric weakness with minimal or no sensory impairment. Currently, a vast evidence supports a direct pathogenic role of IgM anti-GM1 antibodies on disease pathogenesis. Patients with MMN seropositive for GM1-specific IgM antibodies have significantly more weakness, disability and axon loss than patients without these antibodies. During the screening for IgM anti-GM1 antibodies in a cohort of patients with neuropathy we noticed an absence or significant reduction of natural IgM anti-GM1 autoreactivity in some patients with MMN, suggesting a mechanism of self-control of autoreactivity. We aim to understand the lack of natural reactivity against GM1 in MMN patients. METHODS The presence of free IgM anti-GM1 reactivity or its complex to blocking IgG was analysed by combining high performance thin layer chromatography-immunostaining, soluble binding inhibition assays, Protein-G or GM1-affinity columns and dot blot assays. RESULTS We identified in MMN patients an immunoregulation of IgM anti-GM1 antibodies mediated by IgG immunoglobulins characterized by: (i) lack of natural IgM anti-GM1 autoreactivity as a result of a immunoregulatory IgG-dependent mechanism; (ii) presence of natural and disease-associated IgM anti-GM1/IgG blocking Ab complexes in sera; and (iii) high levels of IgG blocking against natural IgM anti-GM1 antibodies (Abs. INTERPRETATION Our observations unmask a spontaneous IgG-dependent mechanism of immunoregulation against IgM anti-GM1 antibodies that could explain, in part, fluctuations in the usually slowly progressive clinical course that characterizes the disease and, at the same time, allows the identification of an autoimmune response against GM1 ganglioside in seronegative patients.
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Affiliation(s)
- Marianna Di Egidio
- División Neurología, Sección Neuroinmunología, Hospital Ramos Mejía, Buenos Aires, Argentina
| | - Cristian R Bacaglio
- Departamento de Química Biológica "Dr Ranwell Caputto"-CIQUIBIC-CONICET, Facultad de Cs. Químicas, Universidad Nacional de Córdoba, Córdoba, Argentina
| | - Rocio Arrejoría
- División Neurología, Sección Neuroinmunología, Hospital Ramos Mejía, Buenos Aires, Argentina
| | - Andrés M Villa
- División Neurología, Sección Neuroinmunología, Hospital Ramos Mejía, Buenos Aires, Argentina
| | - Gustavo A Nores
- Departamento de Química Biológica "Dr Ranwell Caputto"-CIQUIBIC-CONICET, Facultad de Cs. Químicas, Universidad Nacional de Córdoba, Córdoba, Argentina
| | - Pablo H H Lopez
- Departamento de Química Biológica "Dr Ranwell Caputto"-CIQUIBIC-CONICET, Facultad de Cs. Químicas, Universidad Nacional de Córdoba, Córdoba, Argentina
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20
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Müller-Miny L, Sauer R, Schulte-Mecklenbeck A, Gross CC, Kovac S, Schilling M, Beuker C, Wiendl H, Meyer zu Hörste G. Contactin-associated protein 2 autoantibodies can be associated with multifocal motor-like neuropathy: a case report. Ther Adv Neurol Disord 2023; 16:17562864231189323. [PMID: 37599705 PMCID: PMC10434843 DOI: 10.1177/17562864231189323] [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: 04/13/2023] [Accepted: 07/03/2023] [Indexed: 08/22/2023] Open
Abstract
Autoantibodies against contactin-associated protein 2 (CASPR2) are usually associated with autoimmune encephalitis and neuromyotonia. Their association with inflammatory neuropathies has been described in case reports albeit all with distal symmetric manifestation. Here, we report a patient who developed distal arm paresis, dominantly of the right arm, over the course of 1 year. Electroneurography showed a conduction block of motor nerve conduction, nerve ultrasonography a swelling of the right median and ulnar nerve and flow cytometry an increase in natural killer (NK cells) in the blood and natural killer T (NKT) cells in the cerebrospinal fluid (CSF), therefore indicating a multifocal motor neuropathy-like (MMN-like) phenotype. CASPR2 autoantibodies were detected in serum and CSF. Through immunotherapy with intravenous immunoglobulins the patient showed clinical and neurographic improvement. We therefore describe the first association of CASPR2 autoantibodies with a MMN-like clinical manifestation, extending the spectrum of CASPR2-associated diseases.
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Affiliation(s)
- Louisa Müller-Miny
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Raoul Sauer
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Andreas Schulte-Mecklenbeck
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Catharina C. Gross
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Matthias Schilling
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Gerd Meyer zu Hörste
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Building A1, Münster 48149, Germany
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21
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Bos JW, Groen EJN, Budding K, Delemarre EM, Goedee HS, Knol EF, van den Berg LH, van der Pol WL. Multifocal motor neuropathy is not associated with altered innate immune responses to endotoxin. J Neurol Sci 2023; 451:120692. [PMID: 37422959 DOI: 10.1016/j.jns.2023.120692] [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: 01/24/2023] [Revised: 04/19/2023] [Accepted: 05/22/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE Antibody- and complement-mediated peripheral nerve inflammation are central in the pathogenesis of MMN. Here, we studied innate immune responses to endotoxin in patients with MMN and controls to further our understanding of MMN risk factors and disease modifiers. METHODS We stimulated whole blood of 52 patients with MMN and 24 controls with endotoxin and collected plasma. With a multiplex assay, we determined levels of the immunoregulating proteins IL-1RA, IL-1β, IL-6, IL-10, IL-21, TNF-α, IL-8 and CD40L in unstimulated and LPS-stimulated plasma. We compared baseline and stimulated protein levels between patients and controls and correlated concentrations to clinical parameters. RESULTS Protein level changes after stimulation were comparable between groups (p > 0.05). IL-1RA, IL-1β, IL-6 and IL-21 baseline concentrations showed a positive correlation with monthly IVIg dosage (all corrected p-values < 0.016). Patients with anti-GM1 IgM antibodies showed a more pronounced IL-21 increase after stimulation (p 0.048). CONCLUSIONS Altered endotoxin-induced innate immune responses are unlikely to be a susceptibility factor for MMN.
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Affiliation(s)
- Jeroen W Bos
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
| | - Ewout J N Groen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
| | - Kevin Budding
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Eveline M Delemarre
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - H Stephan Goedee
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
| | - Edward F Knol
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Leonard H van den Berg
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
| | - W Ludo van der Pol
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, Utrecht, the Netherlands.
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22
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Klehmet J, Tackenberg B, Haas J, Kieseier BC. Fatigue, depression, and product tolerability during long-term treatment with intravenous immunoglobulin (Gamunex® 10%) in patients with chronic inflammatory demyelinating polyneuropathy. BMC Neurol 2023; 23:207. [PMID: 37237267 DOI: 10.1186/s12883-023-03223-5] [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: 09/20/2022] [Accepted: 04/22/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION/AIMS Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is characterized by progressive weakness and sensory loss, often affecting patient's ability to walk and perform activities of daily living independently. Furthermore, patients often report fatigue and depression which can affect their quality of life. These symptoms were assessed in CIDP patients receiving long-term intravenous immunoglobulin (IVIG) treatment. METHODS GAMEDIS was a multi-center, prospective, non-interventional study in adult CIDP patients treated with IVIG (10%) and followed for two years. Inflammatory Neuropathy Cause and Treatment (INCAT) disability score, Hughes Disability Scale (HDS), Fatigue Severity Scale (FSS), Beck Depression Inventory II (BDI), Short Form-36 health survey (SF-36) and Work Productivity and Activity Impairment Score Attributable to General Health (WPAI-GH) were assessed at baseline and quarterly. Dosing and treatment intervals, changes in outcome parameters, and adverse events (AEs) were analyzed. RESULTS 148 evaluable patients were followed for a mean of 83.3 weeks. The mean maintenance IVIG dose was 0.9 g/kg/cycle (mean cycle interval 38 days). Disability and fatigue remained stable throughout the study. Mean INCAT score: 2.4 ± 1.8 at baseline and 2.5 ± 1.9 at study end. HDS: 74.3% healthy/minor symptoms at baseline and 71.6% at study end. Mean FSS: 4.2 ± 1.6 at baseline and 4.1 ± 1.7 at study end. All patients reported minimal/no depression at baseline and throughout. SF-36 and WPAI-GH scores remained stable. Fifteen patients (9.5%) experienced potentially treatment-related AEs. There were no AEs in 99.3% of infusions. DISCUSSION Long-term treatment of CIDP patients with IVIG 10% in real-world conditions maintained clinical stability on fatigue and depression over 96 weeks. This treatment was well-tolerated and safe.
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Affiliation(s)
- Juliane Klehmet
- Charité - Universitätsmedizin Berlin, Neurocure Clinical Research Center Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Jüdisches Krankenhaus Berlin, Heinz-Galinski-Straße 1, 13347, Berlin-Mitte, Germany
| | - Björn Tackenberg
- Klinik Und Poliklinik Für Neurologie, Baldingerstrasse 1, 35043, Marburg, Germany
| | - Judith Haas
- Jüdisches Krankenhaus Berlin, Heinz-Galinski-Straße 1, 13347, Berlin-Mitte, Germany
| | - Bernd C Kieseier
- Klinik Fur Neurologie, Heinrich-Heine Universität, Moorenstrasse 5, 40225, Düsseldorf, Germany.
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23
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Foesleitner O, Knop KC, Lindenau M, Preisner F, Bäumer P, Heiland S, Bendszus M, Kronlage M. Quantitative MR Neurography in Multifocal Motor Neuropathy and Amyotrophic Lateral Sclerosis. Diagnostics (Basel) 2023; 13:diagnostics13071237. [PMID: 37046455 PMCID: PMC10093201 DOI: 10.3390/diagnostics13071237] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/19/2023] [Indexed: 03/29/2023] Open
Abstract
Background: The aim of this study was to assess the phenotype of multifocal motor neuropathy (MMN) and amyotrophic lateral sclerosis (ALS) in quantitative MR neurography. Methods: In this prospective study, 22 patients with ALS, 8 patients with MMN, and 10 healthy volunteers were examined with 3T MR neurography, using a high-resolution fat-saturated T2-weighted sequence, diffusion-tensor imaging (DTI), and a multi-echo T2-relaxometry sequence. The quantitative biomarkers fractional anisotropy (FA), radial and axial diffusivity (RD, AD), mean diffusivity (MD), cross-sectional area (CSA), T2-relaxation time, and proton spin density (PSD) were measured in the tibial nerve at the thigh and calf, and in the median, radial, and ulnar nerves at the mid-upper arm. Results: MMN showed a characteristic imaging pattern of decreased FA (p = 0.018), increased RD (p = 0.014), increased CSA (p < 0.001), increased T2-relaxation time (p < 0.001), and increased PSD (p = 0.025) in the upper arm nerves compared to ALS and controls. ALS patients did not differ from controls in any imaging marker, nor were there any group differences in the tibial nerve (p > 0.05). Conclusions: MMN shows a characteristic pattern of quantitative DTI and T2-relaxometry parameters in the upper-arm nerves, primarily indicating demyelination. Peripheral nerve changes in ALS seem to be below the detection level of current state-of-the-art quantitative MR neurography.
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24
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Körner S, Maximilian Koch M, Hendrik Müschen L, Seeliger T, Schreiber-Katz O, Gingele S, Stangel M, Dengler R, Petri S, Skripuletz T, Osmanovic A. Cranial nerve involvement in patients with immune-mediated neuropathy: an observational blink reflex study. Clin Neurophysiol 2023; 149:168-175. [PMID: 36989565 DOI: 10.1016/j.clinph.2023.02.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 02/09/2023] [Accepted: 02/27/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE This study aimed to assess cranial nerve involvement in a large adult cohort of patients with immune-mediated neuropathy undergoing immunoglobulin treatment by measuring blink reflex R1 latency prolongation in correlation with clinical findings and nerve conduction studies. METHODS 104 patients underwent blink reflex examination and ulnar nerve conduction studies and were assessed by the Inflammatory Neuropathy Cause and Treatment disability score, the revised Amyotrophic lateral sclerosis functional rating scale (ALSFRS-R) and focused clinical examination. RESULTS Prolonged R1 latencies were identified in 23 of 104 patients (22.1 %). These patients had more severe functional impairments according to the ALSFRS-R, yet only five clinically presented with bulbar dysfunction, facial- or trigeminal nerve impairment. Overall R1 latency was inversely correlated to ulnar motor conduction velocity. In preliminary follow-up assessments under continuous immunoglobulin treatment, prolonged R1 latencies partially improved. CONCLUSIONS Cranial nerve involvement is a common feature in immune-mediated neuropathies and is associated with a more severe disease stage. Here, R1 prolongation was detected less frequently compared to previously reported untreated cohorts. SIGNIFICANCE Blink reflex studies can detect subclinical cranial nerve involvement in immune-mediated neuropathies. Further studies are needed to evaluate the clinical utility of measuring R1 latency.
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Affiliation(s)
- Sonja Körner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | | | - Tabea Seeliger
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Stefan Gingele
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Reinhard Dengler
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | - Alma Osmanovic
- Department of Neurology, Hannover Medical School, Hannover, Germany; Essen Center for Rare Diseases (EZSE), University Hospital Essen, Essen, Germany.
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25
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Naum R, Gwathmey KG. Autoimmune polyneuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:587-608. [PMID: 37562888 DOI: 10.1016/b978-0-323-98818-6.00004-2] [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
The autoimmune peripheral neuropathies with prominent motor manifestations are a diverse collection of unusual peripheral neuropathies that are appreciated in vast clinical settings. This chapter highlights the most common immune-mediated, motor predominant neuropathies excluding acute, and chronic inflammatory demyelinating polyradiculoneuropathy (AIDP and CIDP, respectively). Other acquired demyelinating neuropathies such as distal CIDP and multifocal motor neuropathy will be covered. Additionally, the radiculoplexus neuropathies, resulting from microvasculitis-induced injury to nerve roots, plexuses, and nerves, including diabetic and nondiabetic lumbosacral radiculoplexus neuropathy and neuralgic amyotrophy (i.e., Parsonage-Turner syndrome), will be included. Finally, the motor predominant peripheral neuropathies encountered in association with rheumatological disease, particularly Sjögren's syndrome and rheumatoid arthritis, are covered. Early recognition of these distinct motor predominant autoimmune neuropathies and initiation of immunomodulatory and immunosuppressant treatment likely result in improved outcomes.
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Affiliation(s)
- Ryan Naum
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
| | - Kelly Graham Gwathmey
- Neuromuscular Division, Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States.
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26
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McCombe PA, Hardy TA, Nona RJ, Greer JM. Sex differences in Guillain Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy and experimental autoimmune neuritis. Front Immunol 2022; 13:1038411. [PMID: 36569912 PMCID: PMC9780466 DOI: 10.3389/fimmu.2022.1038411] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/24/2022] [Indexed: 12/13/2022] Open
Abstract
Guillain Barré syndrome (GBS) and its variants, and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP and its variants, are regarded as immune mediated neuropathies. Unlike in many autoimmune disorders, GBS and CIDP are more common in males than females. Sex is not a clear predictor of outcome. Experimental autoimmune neuritis (EAN) is an animal model of these diseases, but there are no studies of the effects of sex in EAN. The pathogenesis of GBS and CIDP involves immune response to non-protein antigens, antigen presentation through non-conventional T cells and, in CIDP with nodopathy, IgG4 antibody responses to antigens. There are some reported sex differences in some of these elements of the immune system and we speculate that these sex differences could contribute to the male predominance of these diseases, and suggest that sex differences in peripheral nerves is a topic worthy of further study.
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Affiliation(s)
- Pamela A. McCombe
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia,*Correspondence: Pamela A. McCombe,
| | - Todd A. Hardy
- Department of Neurology, Concord Hospital, University of Sydney, Sydney, NSW, Australia,Brain & Mind Centre, University of Sydney, Sydney, NSW, Australia
| | - Robert J. Nona
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Judith M. Greer
- Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
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27
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Briani C, Cocito D, Campagnolo M, Doneddu PE, Nobile-Orazio E. Update on therapy of chronic immune-mediated neuropathies. Neurol Sci 2022; 43:605-614. [PMID: 33452933 DOI: 10.1007/s10072-020-04998-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/12/2020] [Indexed: 12/27/2022]
Abstract
Chronic immune-mediated neuropathies, including chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), neuropathies associated with monoclonal gammopathy, and multifocal motor neuropathy (MMN), are a group of disorders deemed to be caused by an immune response against peripheral nerve antigens. Several immune therapies have been reported to be variably effective in these neuropathies including steroids, plasma exchange, and high-dose intravenous (IVIg) or subcutaneous (SCIg) immunoglobulins. These therapies are however far from being invariably effective and may be associated with a number of side effects leading to the use of immunosuppressive agents whose efficacy has not been so far confirmed in randomized trials. More recently, new biological agents, such as rituximab, have proved to be effective in patients with neuropathy associated with IgM monoclonal gammopathy and are currently tested in CIDP.
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Affiliation(s)
- Chiara Briani
- Neurology Unit, Department of Neuroscience, University of Padova, Via Giustiniani, 5, 35128, Padova, Italy.
| | - Dario Cocito
- Istituti Clinici Scientifici Maugeri, Torino, Italy
| | - Marta Campagnolo
- Neurology Unit, Department of Neuroscience, University of Padova, Via Giustiniani, 5, 35128, Padova, Italy
| | - Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Institute, Rozzano, Milan, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Institute, Rozzano, Milan, Italy.,Department of Medical Biotechnology and Translational Medicine, Milan University, Milan, Italy
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28
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Park SB, Li T, Kiernan MC, Garg N, Wilson I, White R, Boggild M, McNabb A, Lee-Archer M, Taylor BV. Prevalence of chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy in two regions of Australia. Muscle Nerve 2022; 66:576-582. [PMID: 36054471 DOI: 10.1002/mus.27698] [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: 12/13/2021] [Revised: 08/03/2022] [Accepted: 08/07/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION/AIMS Immune-mediated neuropathies such as chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN) produce significant disability and often require maintenance treatment. There is a paucity of epidemiological data on these conditions in Australia. METHODS We undertook a prevalence study of CIDP and MMN in North Queensland and Tasmania, coinciding with a national census. Diagnoses were classified against the diagnostic criteria of the European Federation of Neurological Societies/Peripheral Nerve Society. Case ascertainment was undertaken via multiple methods, including survey of local neurologists across public and private clinics, search of neurophysiology, neurology and hospital databases, search of admitted hospital database collections using ICD codes and through immunoglobulin therapy prescription lists. RESULTS The crude prevalence of CIDP was 5.00 per 100,000 (95% confidence interval [CI] 3.79-6.62) and the crude prevalence of MMN was 1.33 per 100,000 (95% CI 0.78-2.27). Prevalence was also investigated using National Blood Authority numbers of cases prescribed immunoglobulin therapy, indicating a CIDP prevalence of 5.72 per 100,000 (95% CI 4.41-7.43) and MMN prevalence of 1.94 per 100,000 (95% CI 1.24-3.03). There was no significant difference between these numbers and those calculated through access of patient records locally. There was no significant difference in prevalence between Tasmania and North Queensland for any category. DISCUSSION This study updates the prevalence of CIDP and MMN in Australia. Understanding the distribution of CIDP and MMN patients and their need for treatment is essential for future resource planning and to enable monitoring and coordination of therapies such as immunoglobulin.
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Affiliation(s)
- Susanna B Park
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Tiffany Li
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Nidhi Garg
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Ian Wilson
- Department of Neurology, Cairns Hospital, Cairns, Australia
| | - Richard White
- Department of Neurology, Townsville University Hospital, Townsville, Australia
| | - Michael Boggild
- Department of Neurology, Townsville University Hospital, Townsville, Australia
| | - Andrew McNabb
- Department of Neurology, Cairns Hospital, Cairns, Australia
| | - Matthew Lee-Archer
- Launceston General Hospital, Tasmanian Health Service, Launceston, Australia
| | - Bruce V Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
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29
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Bae JH, Kwak S. Differential diagnosis of motor weakness in the right lower limb of a 59-year-old male patient. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2022; 39:347-351. [PMID: 36124560 PMCID: PMC9580052 DOI: 10.12701/jyms.2022.00535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 08/25/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Jae Hwa Bae
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
| | - Soyoung Kwak
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
- Corresponding author: Soyoung Kwak, MD, MPH, PhD Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, 170 Hyeonchung-ro, Nam-gu, Daegu 42415, Korea Tel: +82-53-620-3270 • E-mail:
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30
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Polyneuropathy Associated with IgM Monoclonal Gammopathy; Advances in Genetics and Treatment, Focusing on Anti-MAG Antibodies. HEMATO 2022. [DOI: 10.3390/hemato3040045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
With increasing age, the chances of developing either MGUS or polyneuropathy increase as well. In some cases, there is a causative relationship between the IgM M-protein and polyneuropathy. In approximately half of these cases, IgM targets the myelin-associated glycoprotein (MAG). This results in chronic polyneuropathy with slowly progressive, predominantly sensory neurological deficits and distally demyelinating features in nerve conduction studies. Despite the disease being chronic and developing slowly, it can cause considerable impairment. We reviewed English medical publications between 1980 and May 2022 on IgM gammopathy-associated polyneuropathy, with special attention to studies addressing the pathophysiology or treatment of anti-MAG polyneuropathy. Treatment options have been limited to a temporizing effect of intravenous immunoglobulins in some patients and a more sustained effect of rituximab but in only 30 to 55 percent of patients. An increase in our knowledge concerning genetic mutations, particularly the MYD88L265P mutation, led to the development of novel targeted treatment options such as BTK inhibitors. Similarly, due to the increasing knowledge of the pathophysiology of anti-MAG polyneuropathy, new treatment options are emerging. Since anti-MAG polyneuropathy is a rare disease with diverse symptomatology, large trials with good outcome measures are a challenge.
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31
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Beecher G, Howe BM, Shelly S, Nathan P, Mauermann ML, Taylor BV, Spinner RJ, Tracy JA, Dyck PJB, Klein CJ. Plexus MRI helps distinguish the immune-mediated neuropathies MADSAM and MMN. J Neuroimmunol 2022; 371:577953. [PMID: 36007424 DOI: 10.1016/j.jneuroim.2022.577953] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Among immune-mediated neuropathies, clinical-electrophysiological overlap exists between multifocal acquired demyelinating sensory and motor neuropathy (MADSAM) and multifocal motor neuropathy (MMN). Divergent immune pathogenesis, immunotherapy response, and prognosis exist between these two disorders. MRI reports have not shown distinction of these disorders, but biopsy confirmation is lacking in earlier reports. MADSAM nerves are hypertrophic with onion bulbs, inflammation, and edema, whereas MMN findings are limited to multifocal axonal atrophy. OBJECTIVES To understand if plexus MRI can distinguish MADSAM from MMN among pathologically (nerve biopsy) confirmed cases. METHODS Retrospective chart review and blinded plexus MRI review of biopsy-confirmed MADSAM and MMN cases at Mayo Clinic. RESULTS Nine brachial plexuses (MADSAM-5, MMN-4) and 6 lumbosacral plexuses (MADSAM-4, MMN-2) had fascicular biopsies of varied nerves. Median follow-up in MADSAM was 93 months (range: 7-180) and 27 (range: 12-109) in MMN (p = 0.34). MRI hypertrophy occurred solely in MADSAM (89%, 8/9) with T2-hyperintensity in both. There was no correlation between time to imaging for hypertrophy, symptom onset age, or motor neuropathy impairments (mNIS). At last follow-up, on diverse immunotherapies mNIS improved in MADSAM (median - 4, range: -22 to 0), whereas MMN worsened (median 3, range: 0 to 6, p = 0.03) on largely IVIG. CONCLUSION Nerve hypertrophy on plexus MRI helps distinguish MMN from MADSAM, where better immunotherapy treatment outcomes were observed. These findings are consistent with the immune pathogenesis seen on biopsies. Radiologic distinction is possible independent of time to imaging and extent of motor deficits, suggesting MRI is helpful in patients with uncertain clinical-electrophysiologic diagnosis, especially motor-onset MADSAM.
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Affiliation(s)
- Grayson Beecher
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America
| | - Benjamin M Howe
- Department of Radiology, Mayo Clinic, Rochester, MN, United States of America
| | - Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Department of Neurology, Chaim Sheba Medical Centre, Sackler Faculty Institute, Tel Aviv, Israel
| | - P Nathan
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America
| | | | - Bruce V Taylor
- Menzies Institute for Medical Research, University of Tasmania, Australia
| | - Robert J Spinner
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States of America
| | - Jennifer A Tracy
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America
| | - P James B Dyck
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America
| | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN, United States of America; Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States of America.
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32
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Keh RYS, Shah S, Lilleker JB, Lavin T, Morrow J, Carr AS, Lunn MP. Pragmatic guide to peripheral nerve disease and the role of clinical biomarkers. Pract Neurol 2022; 22:pn-2022-003438. [PMID: 35850979 DOI: 10.1136/pn-2022-003438] [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: 06/13/2022] [Indexed: 11/03/2022]
Abstract
In clinical neurology practice, there are few sensitive, specific and responsive serological biomarkers reflecting pathological processes affecting the peripheral nervous system. Instead, we rely on surrogate multimodality biomarkers for diagnosis and management. Correct use and interpretation of the available tests is essential to ensure that appropriate treatments are used and adjusted in a timely fashion. The incorrect application or interpretation of biomarkers can result in misdiagnosis and delays in appropriate treatment. Here, we discuss the uses and limitations of such biomarkers and discuss possible future developments.
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Affiliation(s)
- Ryan Yann Shern Keh
- Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Sachit Shah
- Lysholm Department of Neuroradiology, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - James B Lilleker
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
- Division of Musculoskeletal and Dermatological, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Tim Lavin
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Jasper Morrow
- Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
- Lysholm Department of Neuroradiology, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Aisling S Carr
- Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
- Institute of Neurology, University College London, London, UK
| | - Michael P Lunn
- Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
- Institute of Neurology, University College London, London, UK
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33
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Eren F, Aygul R, Tenekeci S, Ozturk S. Multifocal motor neuropathy after SARS-CoV-2 vaccination: a causal or coincidental association? J Int Med Res 2022; 50:3000605221110709. [PMID: 35818160 PMCID: PMC9280831 DOI: 10.1177/03000605221110709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Multifocal motor neuropathy (MMN) is an immune-mediated and acquired demyelinating motor polyneuropathy. Several cases of polyneuropathy associated with severe acquired respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination have been reported. However, MMN has not been reported as a complication of SARS-CoV-2 vaccination. In this study, we report a case of MMN with progressive muscle weakness following the second dose of the Pfizer-BioNTech mRNA vaccine. It was diagnosed by clinical evaluation and electroneuromyography. SARS-CoV-2 vaccination is increasing rapidly all over the world. Some cases of polyneuropathy, especially Guillain–Barré syndrome, have been reported after vaccination. This is the first case report of MMN after SARS-CoV-2 vaccination.
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Affiliation(s)
- Fettah Eren
- Selcuk University, School of Medicine, Department of Neurology, Konya, Turkey
| | - Recep Aygul
- Selcuk University, School of Medicine, Department of Neurology, Konya, Turkey
| | - Sevde Tenekeci
- Selcuk University, School of Medicine, Department of Neurology, Konya, Turkey
| | - Serefnur Ozturk
- Selcuk University, School of Medicine, Department of Neurology, Konya, Turkey
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34
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Ma X, Du L, Yuan W, Han T. Application and Research Progress of High Frequency Ultrasound in the Diagnosis of Chronic Inflammatory Neuropathies. Front Neurol 2022; 13:860144. [PMID: 35812115 PMCID: PMC9263972 DOI: 10.3389/fneur.2022.860144] [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: 01/22/2022] [Accepted: 04/25/2022] [Indexed: 11/24/2022] Open
Abstract
In recent years, clinicians have gradually improved their understanding of multiple neuropathy and have done some studies about chronic inflammatory neuropathies, for example, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and Lewis-Sumne syndrome. The early diagnosis is very important for the next step treatment and long-term prognosis. At present, the disease mainly depends on clinical and neural electrophysiological examination, but imaging studies are few. In recent years, with the rapid development of high frequency ultrasound, it could clearly show the morphology of the nerve, and it has been an emerging diagnosis tool of polyneuropathies. This article mainly reviews the application and the latest research progress of high frequency ultrasound in these diseases.
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Affiliation(s)
- Xishun Ma
- Department of Ultrasound, Qingdao Municipal Hospital, Qingdao, China
| | - Lizhen Du
- Department of Ultrasound, Qingdao Municipal Hospital, Qingdao, China
| | - Wenqing Yuan
- Department of Primary Medical Management, Qingdao Municipal Hospital, Qingdao, China
- Wenqing Yuan
| | - Tongliang Han
- Department of Ultrasound, Qingdao Municipal Hospital, Qingdao, China
- *Correspondence: Tongliang Han
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35
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Akbar A, Blume GM, Creeden S, Ahmad S. COVID-19 and MOG-IgG–associated acquired demyelinating polyneuropathy compatible with chronic inflammatory demyelinating polyneuropathy in a previously healthy girl. Proc AMIA Symp 2022; 35:719-721. [DOI: 10.1080/08998280.2022.2088466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Asra Akbar
- OSF Saint Francis Medical Center, Peoria, Illinois
| | | | - Sean Creeden
- OSF Saint Francis Medical Center, Peoria, Illinois
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36
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Watanabe S, Sekiguchi K, Noda Y, Matsumoto R. Clinical Utility of Repetitive Nerve Stimulation Test in Differentiating Multifocal Motor Neuropathy From Progressive Muscular Atrophy. J Clin Neuromuscul Dis 2022; 23:175-182. [PMID: 35608640 PMCID: PMC9126258 DOI: 10.1097/cnd.0000000000000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
OBJECTIVES To evaluate the utility of repetitive nerve stimulation test (RNS) for differentiating multifocal motor neuropathy (MMN) and progressive muscular atrophy (PMA). METHODS We retrospectively enrolled 20 patients with MMN or PMA. We extracted the results of the initial 3-Hz RNS in the ulnar and accessory nerves and compared the percentage and frequency of abnormal decremental responses between both groups. RESULTS RNS was performed in 8 ulnar and 9 accessory nerves in patients with MMN, and in 8 ulnar and 10 accessory nerves in patients with PMA. Patients with MMN had a significantly lower decrement percentage (0.6 ± 4.0% in MMN vs. 10.3 ± 6.5% in PMA, P < 0.01) and frequency of abnormal decremental response (0 of 9 in MMN vs. 6 of 10 in PMA, P = 0.01) than patients with PMA in the accessory nerve. CONCLUSIONS The RNS has clinical utility for differentiating MMN from PMA.
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Affiliation(s)
- Shunsuke Watanabe
- Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kenji Sekiguchi
- Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshikatsu Noda
- Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Riki Matsumoto
- Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan
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37
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Rumsey JW, Lorance C, Jackson M, Sasserath T, McAleer CW, Long CJ, Goswami A, Russo MA, Raja SM, Gable KL, Emmett D, Hobson-Webb LD, Chopra M, Howard JF, Guptill JT, Storek MJ, Alonso-Alonso M, Atassi N, Panicker S, Parry G, Hammond T, Hickman JJ. Classical Complement Pathway Inhibition in a "Human-On-A-Chip" Model of Autoimmune Demyelinating Neuropathies. ADVANCED THERAPEUTICS 2022; 5:2200030. [PMID: 36211621 PMCID: PMC9540753 DOI: 10.1002/adtp.202200030] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Indexed: 07/21/2023]
Abstract
Chronic autoimmune demyelinating neuropathies are a group of rare neuromuscular disorders with complex, poorly characterized etiology. Here we describe a phenotypic, human-on-a-chip (HoaC) electrical conduction model of two rare autoimmune demyelinating neuropathies, chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN), and explore the efficacy of TNT005, a monoclonal antibody inhibitor of the classical complement pathway. Patient sera was shown to contain anti-GM1 IgM and IgG antibodies capable of binding to human primary Schwann cells and induced pluripotent stem cell derived motoneurons. Patient autoantibody binding was sufficient to activate the classical complement pathway resulting in detection of C3b and C5b-9 deposits. A HoaC model, using a microelectrode array with directed axonal outgrowth over the electrodes treated with patient sera, exhibited reductions in motoneuron action potential frequency and conduction velocity. TNT005 rescued the serum-induced complement deposition and functional deficits while treatment with an isotype control antibody had no rescue effect. These data indicate that complement activation by CIDP and MMN patient serum is sufficient to mimic neurophysiological features of each disease and that complement inhibition with TNT005 was sufficient to rescue these pathological effects and provide efficacy data included in an investigational new drug application, demonstrating the model's translational potential.
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Affiliation(s)
- John W Rumsey
- Hesperos, Inc., 12501 Research Parkway, Suite 100, Orlando, FL 32826
| | - Case Lorance
- Hesperos, Inc., 12501 Research Parkway, Suite 100, Orlando, FL 32826
| | - Max Jackson
- Hesperos, Inc., 12501 Research Parkway, Suite 100, Orlando, FL 32826
| | - Trevor Sasserath
- Hesperos, Inc., 12501 Research Parkway, Suite 100, Orlando, FL 32826
| | | | | | - Arindom Goswami
- NanoScience Technology Center, University of Central Florida, Orlando, Florida, USA
| | - Melissa A Russo
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Shruti M Raja
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Karissa L Gable
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Doug Emmett
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Lisa D Hobson-Webb
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Manisha Chopra
- Department of Neurology, The University of North Carolina - Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - James F Howard
- Department of Neurology, The University of North Carolina - Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Jeffrey T Guptill
- Division of Neuromuscular Disease, Department of Neurology, Duke University Medical Center, Box 3403, Durham, NC, USA
| | - Michael J Storek
- Sanofi, Immunology and Inflammation, 225 2 Ave, Waltham, MA, 02451 USA
| | | | - Nazem Atassi
- Sanofi, Neurology Early Development, 50 Binney Street, Cambridge, MA, 02142 USA
| | - Sandip Panicker
- Bioverativ, a Sanofi company, 225 2 Ave, Waltham, MA, 02451 USA
| | - Graham Parry
- Bioverativ, a Sanofi company, 225 2 Ave, Waltham, MA, 02451 USA
| | - Timothy Hammond
- Sanofi, Neurological Diseases, 49 New York Ave, Framingham, MA, 01701 USA
| | - James J Hickman
- Hesperos, Inc., 12501 Research Parkway, Suite 100, Orlando, FL 32826
- NanoScience Technology Center, University of Central Florida, Orlando, Florida, USA
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38
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Kmezic I, Samuelsson K, Finn A, Upate Z, Blennow K, Zetterberg H, Press R. Neurofilament light chain and total tau in the differential diagnosis and prognostic evaluation of acute and chronic inflammatory polyneuropathies. Eur J Neurol 2022; 29:2810-2822. [PMID: 35638376 PMCID: PMC9542418 DOI: 10.1111/ene.15428] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/28/2022] [Accepted: 05/12/2022] [Indexed: 11/29/2022]
Abstract
Background and Purpose To investigate the diagnostic and prognostic value of axonal injury biomarkers in patients with inflammatory polyneuropathies. Methods Neurofilament light chain (NfL) and total tau (T‐tau) were measured in the cerebrospinal fluid (CSF) and plasma in 41 patients with Guillain–Barré syndrome (GBS), 32 patients with chronic inflammatory demyelinating polyneuropathy (CIDP), 10 with paraproteinemia‐related demyelinating polyneuropathy (PDN), and 8 with multifocal motor neuropathy (MMN), in comparison with 39 disease‐free controls and 59 other controls. Outcome was measured with the GBS‐disability score (GBS‐ds) or Inflammatory Neuropathy Cause and Treatment (INCAT) disability score. Results Neurofilament light chain levels in CSF and plasma were higher in GBS, CIDP, and PDN vs. disease‐free controls. Patients with MMN had higher NfL levels in plasma vs. disease‐free controls, but lower levels in CSF and plasma vs. patients with amyotrophic lateral sclerosis (ALS). T‐tau levels in plasma were higher in GBS, CIDP, PDN, and MMN vs. all control groups. Neurofilament light chain levels in CSF and plasma in patients with GBS correlated with GBS‐ds, as higher levels were associated with inability to run after 6 and 12 months. NfL levels in CSF and plasma in CIDP did not correlate significantly with outcome. Conclusions Acute and chronic inflammatory neuropathies are associated with an increase in levels of NfL in CSF and plasma, but NfL is validated as a prognostic biomarker only in GBS. NfL could be used in differentiating patients with MMN from ALS. T‐tau in plasma is a novel biomarker that could be used in a diagnostic assessment of patients with acute and chronic inflammatory polyneuropathies.
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Affiliation(s)
- I Kmezic
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - K Samuelsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - A Finn
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Z Upate
- Department of Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - K Blennow
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Psychology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - H Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Psychology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK.,Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - R Press
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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39
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Nunez MC, Nepomuceno BLM, Tiongson MLGP. Multifocal Motor Neuropathy With Cranial Nerve Involvement and Vocal Cord Paralysis: A Case Report. Cureus 2022; 14:e25179. [PMID: 35746993 PMCID: PMC9207705 DOI: 10.7759/cureus.25179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/05/2022] Open
Abstract
Multifocal motor neuropathy (MMN) is a progressive, multifocal weakness, which typically begins and predominates in the upper extremities with the absence of a sensory deficit and a hallmark electrophysiologic finding of conduction block. We describe a case of an adult male with MMN who developed both cranial nerve involvement and vocal cord paralysis. The patient presented with left shoulder weakness without sensory loss followed by hoarseness of voice and later developed tongue deviation and wasting of the left sternocleidomastoid and left trapezius muscle. Laryngeal electromyography (EMG) showed findings evident for a focal mononeuropathy involving the left recurrent laryngeal nerve. EMG and nerve conduction studies (EMG NCV) of the upper extremities showed evidence for a multifocal mainly motor neuropathy involving the left spinal accessory and hypoglossal nerves, combined with the presence of median and ulnar proximal conduction blocks bilaterally. Given the clinical presentation and electrophysiologic findings of conduction block, the patient was managed as a case of MMN and received the standard treatment with Intravenous Immunoglobulin (IVIg). Upon follow-up, there was an improvement in symptoms and no recurrence of motor weakness and hoarseness of voice. There are a few case reports about MMN but none with multiple lower cranial nerve involvement.
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40
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Briani C, Visentin A. Therapeutic Monoclonal Antibody Therapies in Chronic Autoimmune Demyelinating Neuropathies. Neurotherapeutics 2022; 19:874-884. [PMID: 35349079 PMCID: PMC9294114 DOI: 10.1007/s13311-022-01222-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 02/07/2023] Open
Abstract
Autoimmune diseases of the peripheral nervous system have so far been treated mainly with exogenous high-dose intravenous immunoglobulins (IVIg), that act through several mechanisms, including neutralization of pathogenic autoantibodies, modulation of lymphocyte activity, interference with antigen presentation, and interaction with Fc receptors, cytokines, and the complement system. Other therapeutic strategies have recently been developed, in part to address the increasing shortage of IVIg, prime among which is the use of B cell depleting monoclonal antibodies, or small molecule inhibitors targeting the B-cell specific kinases. Rituximab, a chimeric monoclonal antibody against CD20 + B lymphocytes, is currently the most used, especially in anti-MAG antibody neuropathy and autoimmune neuropathies with antibodies to nodal/paranodal antigens that are unresponsive to IVIg. After several reports of its efficacy in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), rituximab is currently under investigation in three Phase 2 trials in CIDP. In addition, the possible role of complement activation in the pathogenesis of chronic autoimmune neuropathies has brought into consideration drugs that can block the complement cascade, such as eculizumab, a monoclonal antibody already assessed in acute polyradiculoneuropathies, and approved for myasthenia gravis. Preliminary data on eculizumab in multifocal motor neuropathy have been published, but randomized controlled studies are pending. Moreover, the neonatal Fc receptor, that recycles IgGs by preventing their lysosome degradation, is an important and attractive pharmacological target. Antibodies against FcRn, which reduce circulating IgG (both pathogenic and non-pathogenic) have been developed. The FcRn blocker efgartigimod, a humanized IgG1-derived Fc fragment, which competitively inhibits the FcRn, has recently been approved for the treatment of myasthenia gravis and is currently under investigation in CIDP. In addition, the anti-human FcRn monoclonal antibody rozanolixizumab is currently being assessed in phase 2 trials in CIDP. However, none of the abovementioned monoclonal antibodies is currently approved for treatment of any immune-mediated neuropathies. While more specific and individualized therapies are being developed, the possibility of combined treatments targeting different pathogenic mechanisms deserves consideration as well.
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Affiliation(s)
- Chiara Briani
- Department of Neurosciences, Neurology Unit, University of Padova, Padova, Italy.
| | - Andrea Visentin
- Department of Medicine, Hematology Unit, University of Padova, Padova, Italy
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41
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Gonzalez NL, Juel VC, Živković SA. A Case of Probable Multifocal Motor Neuropathy With Clinical Stability for Ten Years After a Single Treatment of Rituximab. J Clin Neuromuscul Dis 2022; 23:136-142. [PMID: 35188910 DOI: 10.1097/cnd.0000000000000358] [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: 11/25/2022]
Abstract
ABSTRACT Multifocal motor neuropathy is a rare, immune-mediated motor neuropathy with asymmetric, often debilitating progressive weakness. The efficacy of intravenous immunoglobulin in this disease is well established; however, the response typically wanes over time. No other agent has shown similar therapeutic efficacy. We describe a case of anti-ganglioside GM1 IgM-positive multifocal motor neuropathy with typical incomplete and diminishing response to intravenous immunoglobulin over time. Sixteen years after symptom onset, rituximab was administered at 2 g/m2 over 2 weeks. No significant progression of disease has occurred over the following 10 years despite no additional treatments, including intravenous immunoglobulin, being given. Only case reports and small, mostly uncontrolled studies have reported the use of rituximab in multifocal motor neuropathy with mixed results. However, given its potential benefits and lack of an established second-line agent, treatment with rituximab may be considered in select patients with refractory multifocal motor neuropathy.
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Affiliation(s)
| | - Vern C Juel
- Department of Neurology, Duke University Hospital, Durham, NC; and
| | - Saša A Živković
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
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42
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Hiew FL, Thit WM, Alexander M, Thirugnanam U, Siritho S, Tan K, Mya Aye SM, Ohnmar O, Estiasari R, Yassin N, Pasco PM, Keosodsay SS, Trong Nghia HT, Islam MDB, Wong SK, Lee S, Chhabra A, Viswanathan S. Consensus recommendation on the use of therapeutic plasma exchange for adult neurological diseases in Southeast Asia from the Southeast Asia therapeutic plasma exchange consortium. J Cent Nerv Syst Dis 2022; 13:11795735211057314. [PMID: 35173510 PMCID: PMC8842418 DOI: 10.1177/11795735211057314] [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: 05/06/2021] [Accepted: 10/12/2021] [Indexed: 11/30/2022] Open
Abstract
Therapeutic plasma exchange (TPE) is an effective and affordable treatment option in most parts of Southeast Asia (SEA). In 2018, the SEA TPE Consortium (SEATPEC) was established, consisting of regional neurologists working to improve outcome of various autoimmune neurological diseases. We proposed an immunotherapeutic guideline prioritizing TPE for this region. We reviewed disease burden, evidence-based treatment options, and major guidelines for common autoimmune neurological disorders seen in SEA. A modified treatment algorithm based on consensus agreement by key-opinion leaders was proposed. Autoimmune antibody diagnostic testing through collaboration with accredited laboratories was established. Choice of first-line immunotherapies (IVIg/corticosteroid/TPE) is based on available evidence, clinicians’ experience, contraindications, local availability, and affordability. TPE could be chosen as first-line therapy for GBS, CIDP, MG (acute/short term), IgG, A paraproteinemic neuropathy, and NMDAR encephalitis. Treatment is stopped for acute monophasic conditions such as GBS and ADEM following satisfactory outcome. For chronic immune disorders, a therapy taper or long-term maintenance therapy is recommended depending on the defined clinical state. TPE as second-line treatment is indicated for IVIg or corticosteroids refractory cases of ADEM, NMOSD (acute), MG, and NMDAR/LGI1/CASPR2/Hashimoto’s encephalitis. With better diagnosis, treatment initiation with TPE is a sustainable and effective immunotherapy for autoimmune neurological diseases in SEA.
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Affiliation(s)
- Fu Liong Hiew
- Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
- Dr Fu Liong Hiew, Physician and Neurologist, Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia Jalan Pahang, Wilayah Persekutuan Kuala Lumpur 50586, Malaysia.
| | - Win Min Thit
- University of Medicine 1, Yangon, Myanmar
- Yangon General Hospital/University of Medicine 1, Yangon, Myanmar
| | - Mathew Alexander
- Brunei Neuroscience Stroke and Rehabilitation Centre, Pantai Jerudong Specialist Centre, Brunei Darussalam
| | | | - Sasitorn Siritho
- Division of Neurology, Faculty of Medicine, Siriraj Hospital, Bumrungrad International Hospital, Bangkok, Thailand
| | - Kevin Tan
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | | | - Ohnmar Ohnmar
- University of Medicine 1, Yangon, Myanmar
- Yangon General Hospital/University of Medicine 1, Yangon, Myanmar
| | - Riwanti Estiasari
- Department of Neurology, Cipto Mangunkusumo Hospital/Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | | | | | | | | | - MD Badrul Islam
- Laboratory Sciences and Services Division (LSSD), The International Centre for Diarrhoeal Disease, Dhaka, Bangladesh
| | - Sing Keat Wong
- Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Shirley Lee
- Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
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Riva N, Gentile F, Cerri F, Gallia F, Podini P, Dina G, Falzone YM, Fazio R, Lunetta C, Calvo A, Logroscino G, Lauria G, Corbo M, Iannaccone S, Chiò A, Lazzerini A, Nobile-Orazio E, Filippi M, Quattrini A. Phosphorylated TDP-43 aggregates in peripheral motor nerves of patients with amyotrophic lateral sclerosis. Brain 2022; 145:276-284. [PMID: 35076694 PMCID: PMC8967102 DOI: 10.1093/brain/awab285] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/07/2021] [Accepted: 07/18/2021] [Indexed: 12/27/2022] Open
Abstract
Phosphorylated TDP-43 (pTDP-43) aggregates in the cytoplasm of motor neurons and neuroglia in the brain are one of the pathological hallmarks of amyotrophic lateral sclerosis. Although the axons exceed the total volume of motor neuron soma by several orders of magnitude, systematic studies investigating the presence and distribution of pTDP-43 aggregates within motor nerves are still lacking. The aim of this study is to define the TDP-43/pTDP-43 pathology in diagnostic motor nerve biopsies performed on a large cohort of patients presenting with a lower motor neuron syndrome and to assess whether this might be a discriminating tissue biomarker for amyotrophic lateral sclerosis and non-amyotrophic lateral sclerosis cases. We retrospectively evaluated 102 lower motor neuron syndrome patients referred to our centre for a diagnostic motor nerve biopsy. Histopathological criteria of motor neuron disease and motor neuropathy were applied by two independent evaluators, who were blind to clinical data. TDP-43 and pTDP-43 were evaluated by immunohistochemistry, and results compared to final clinical diagnosis. We detected significant differences between amyotrophic lateral sclerosis and non-amyotrophic lateral sclerosis cases in pTDP-43 expression in myelinated fibres: axonal accumulation was detected in 98.2% of patients with amyotrophic lateral sclerosis versus 30.4% of non-amyotrophic lateral sclerosis samples (P < 0.0001), while concomitant positive staining in Schwan cell cytoplasm was found in 70.2% of patients with amyotrophic lateral sclerosis versus 17.4% of patients who did not have amyotrophic lateral sclerosis (P < 0.001). Importantly, we were also able to detect pTDP-43 aggregates in amyotrophic lateral sclerosis cases displaying normal features at standard histopathological analysis. Our findings demonstrated that a specific pTDP-43 signature is present in the peripheral nervous system of patients with amyotrophic lateral sclerosis, and could be exploited as a specific, accessible tissue biomarker. The detection of pTDP-43 aggregates within motor nerves of living patients with amyotrophic lateral sclerosis, occurring before axonal degeneration, suggests that this is an early event that may contribute to amyotrophic lateral sclerosis pathogenesis.
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Affiliation(s)
- Nilo Riva
- Experimental Neuropathology Unit, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, 20132, Milan, Italy
- Neurology Unit and Neurorehabilitation Unit, San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Francesco Gentile
- Experimental Neuropathology Unit, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Federica Cerri
- Experimental Neuropathology Unit, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, 20132, Milan, Italy
- Neurology Unit and Neurorehabilitation Unit, San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Francesca Gallia
- Neuromuscular and Neuroimmunology Service, Department of Medical Biotechnology and Translational Medicine, Humanitas Clinical and Research Institute, Milan University, 20089 Rozzano, Milan, Italy
| | - Paola Podini
- Experimental Neuropathology Unit, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Giorgia Dina
- Experimental Neuropathology Unit, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Yuri Matteo Falzone
- Experimental Neuropathology Unit, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, 20132, Milan, Italy
- Neurology Unit and Neurorehabilitation Unit, San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Raffaella Fazio
- Neurology Unit and Neurorehabilitation Unit, San Raffaele Scientific Institute, 20132, Milan, Italy
| | | | - Andrea Calvo
- Rita Levi Montalcini Department of Neuroscience, University of Turin, 10126 Turin, Italy
| | | | - Giuseppe Lauria
- 3rd Neurology Unit and Motor Neuron Disease Center, IRCCS Foundation ‘Carlo Besta’ Neurological Institute, 20133, Milan, Italy
- Department of Biomedical and Clinical and Sciences ‘Luigi Sacco’, University of Milan, 20157, Milan, Italy
| | - Massimo Corbo
- Department of Neurorehabilitation Sciences, Casa Cura Policlinico, 20144, Milan, Italy
| | - Sandro Iannaccone
- Department of Clinical Neurosciences, San Raffaele Scientific Institute, 20132, Milan, Italy
| | - Adriano Chiò
- Rita Levi Montalcini Department of Neuroscience, University of Turin, 10126 Turin, Italy
| | - Alberto Lazzerini
- Hand Surgery Department, IRCCS Orthopedic Institute Galeazzi, 20161, Milan, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, Department of Medical Biotechnology and Translational Medicine, Humanitas Clinical and Research Institute, Milan University, 20089 Rozzano, Milan, Italy
| | - Massimo Filippi
- Neurology Unit and Neurorehabilitation Unit, San Raffaele Scientific Institute, 20132, Milan, Italy
- Neurophysiology Unit, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
- Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, 20132, Milan, Italy
- Vita-Salute San Raffaele University, 20132, Milan, Italy
| | - Angelo Quattrini
- Experimental Neuropathology Unit, Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute, 20132, Milan, Italy
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Keddie S, Eftimov F, van den Berg LH, Brassington R, de Haan RJ, van Schaik IN. Immunoglobulin for multifocal motor neuropathy. Cochrane Database Syst Rev 2022; 1:CD004429. [PMID: 35015296 PMCID: PMC8751207 DOI: 10.1002/14651858.cd004429.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Multifocal motor neuropathy (MMN) is a rare, probably immune-mediated disorder characterised by slowly progressive, asymmetric, distal weakness of one or more limbs with no objective loss of sensation. It may cause prolonged periods of disability. Treatment options for MMN are few. People with MMN do not usually respond to steroids or plasma exchange. Uncontrolled studies have suggested a beneficial effect of intravenous immunoglobulin (IVIg). This is an update of a Cochrane Review first published in 2005, with an amendment in 2007. We updated the review to incorporate new evidence. OBJECTIVES To assess the efficacy and safety of intravenous and subcutaneous immunoglobulin in people with MMN. SEARCH METHODS We searched the following databases on 20 April 2021: the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, and WHO ICTRP for randomised controlled trials (RCTs) and quasi-RCTs, and checked the reference lists of included studies. SELECTION CRITERIA We considered RCTs and quasi-RCTs examining the effects of any dose of IVIg and subcutaneous immunoglobulin (SCIg) in people with definite or probable MMN for inclusion in the review. Eligible studies had to have measured at least one of the following outcomes: disability, muscle strength, or electrophysiological conduction block. We used studies that reported the frequency of adverse effects to assess safety. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed the literature searches to identify potentially relevant trials, assessed risk of bias of included studies, and extracted data. We followed standard Cochrane methodology. MAIN RESULTS Six cross-over RCTs including a total of 90 participants were suitable for inclusion in the review. Five RCTs compared IVIg to placebo, and one compared IVIg to SCIg. Four of the trials comparing IVIg versus placebo involved IVIg-naive participants (induction treatment). In the other two trials, participants were known IVIg responders receiving maintencance IVIg at baseline and were then randomised to maintenance treatment with IVIg or placebo in one trial, and IVIg or SCIg in the other. Risk of bias was variable in the included studies, with three studies at high risk of bias in at least one risk of bias domain. IVIg versus placebo (induction treatment): three RCTs including IVIg-naive participants reported a disability measure. Disability improved in seven out of 18 (39%) participants after IVIg treatment and in two out of 18 (11%) participants after placebo (risk ratio (RR) 3.00, 95% confidence interval (CI) 0.89 to 10.12; 3 RCTs, 18 participants; low-certainty evidence). The proportion of participants with an improvement in disability at 12 months was not reported. Strength improved in 21 out of 27 (78%) IVIg-naive participants treated with IVIg and one out of 27 (4%) participants who received placebo (RR 11.00, 95% CI 2.86 to 42.25; 3 RCTs, 27 participants; low-certainty evidence). IVIg treatment may increase the proportion of people with resolution of at least one conduction block; however, the results were also consistent with no effect (RR 7.00, 95% CI 0.95 to 51.70; 4 RCTs, 28 participants; low-certainty evidence). IVIg versus placebo (maintenance treatment): a trial that included participants on maintenance IVIg treatment reported an increase in disability in 17 out of 42 (40%) people switching to placebo and seven out of 42 (17%) remaining on IVIg (RR 2.43, 95% CI 1.13 to 5.24; 1 RCT, 42 participants; moderate-certainty evidence) and a decrease in grip strength in 20 out of 42 (48%) participants after a switch to placebo treatment compared to four out of 42 (10%) remaining on IVIg (RR 0.20, 95% CI 0.07 to 0.54; 1 RCT, 42 participants; moderate-certainty evidence). Adverse events, IVIg versus placebo (induction or maintenance): four trials comparing IVIg and placebo reported adverse events, of which data from two studies could be meta-analysed. Transient side effects were reported in 71% of IVIg-treated participants versus 4.8% of placebo-treated participants in these studies. The pooled RR for the development of side effects was 10.33 (95% CI 2.15 to 49.77; 2 RCTs, 21 participants; very low-certainty evidence). There was only one serious side effect (pulmonary embolism) during IVIg treatment. IVIg versus SCIg (maintenance treatment): the trial that compared continuation of IVIg maintenance versus SCIg maintenance did not measure disability. The evidence was very uncertain for muscle strength (standardised mean difference 0.08, 95% CI -0.84 to 1.00; 1 RCT, 9 participants; very low-certainty evidence). The evidence was very uncertain for the number of people with side effects attributable to treatment (RR 0.50, 95% CI 0.18 to 1.40; 1 RCT, 9 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Low-certainty evidence from three small RCTs shows that IVIg may improve muscle strength in people with MMN, and low-certainty evidence indicates that it may improve disability; the estimate of the magnitude of improvement of disability has wide CIs and needs further studies to secure its significance. Based on moderate-certainty evidence, it is probable that most IVIg responders deteriorate in disability and muscle strength after IVIg withdrawal. SCIg might be an alternative treatment to IVIg, but the evidence is very uncertain. More research is needed to identify people in whom IVIg withdrawal is possible and to confirm efficacy of SCIg as an alternative maintenance treatment.
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Affiliation(s)
- Stephen Keddie
- Faculty of Brain Sciences, Institute of Neurology, London, UK
| | - Filip Eftimov
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Leonard H van den Berg
- Department of Neurology, University Medical Center Utrecht, Brain Center Rudolf Magnus, Utrecht, Netherlands
| | - Ruth Brassington
- Queen Square Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Rob J de Haan
- Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Ivo N van Schaik
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Cheng AC, Lin TY, Wang NC. Immune Reconstitution Inflammatory Syndrome Induced by Mycobacterium avium Complex Infection Presenting as Chronic Inflammatory Demyelinating Polyneuropathy in a Young AIDS Patient. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010110. [PMID: 35056418 PMCID: PMC8779113 DOI: 10.3390/medicina58010110] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/05/2022] [Accepted: 01/05/2022] [Indexed: 12/26/2022]
Abstract
Antiretroviral therapy (ART) can restore protective immune responses against opportunistic infections (OIs) and reduce mortality in patients with human immunodeficiency virus (HIV) infections. Some patients treated with ART may develop immune reconstitution inflammatory syndrome (IRIS). Mycobacterium avium complex (MAC)-related IRIS most commonly presents as lymphadenitis, soft-tissue abscesses, and deteriorating lung infiltrates. However, neurological presentations of IRIS induced by MAC have been rarely described. We report the case of a 31-year-old man with an HIV infection. He developed productive cough and chronic inflammatory demyelinating polyneuropathy (CIDP) three months after the initiation of ART. He experienced an excellent virological and immunological response. Sputum culture grew MAC. The patient was diagnosed with MAC-related IRIS presenting as CIDP, based on his history and laboratory, radiologic, and electrophysiological findings. Results: Neurological symptoms improved after plasmapheresis and intravenous immunoglobulin (IVIG) treatment. To our knowledge, this is the first reported case of CIDP due to MAC-related IRIS. Clinicians should consider MAC-related IRIS in the differential diagnosis of CIDP in patients with HIV infections following the initiation of ART.
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Affiliation(s)
- An-Che Cheng
- Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 11490, Taiwan;
| | - Te-Yu Lin
- Division of Infectious Disease and Tropical Medicine, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 11490, Taiwan;
| | - Ning-Chi Wang
- Division of Infectious Disease and Tropical Medicine, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei City 11490, Taiwan;
- Correspondence: ; Tel.: +886-2-287927257
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46
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Goedee HS, Rajabally YA. Evidence base for investigative and therapeutic modalities in chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy. Neurodegener Dis Manag 2022; 12:35-47. [PMID: 35007438 DOI: 10.2217/nmt-2021-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy, its variants and multifocal motor neuropathy belong to a spectrum of peripheral nerve disorders with complex dysimmune disease mechanisms. Awareness of the unique clinical phenotypes but also heterogeneity between patients is vital to arrive at early suspicion and ordering appropriate tests. This includes requirements for optimal electrodiagnostic protocol, aimed to capture sufficient electrophysiologic evidence for relevant abnormalities, a case-based approach on the eventual need to further expand the diagnostic armamentarium and correct reading of their results. Considerable phenotypical variation, diverse combinations of abnormalities found on diagnostic tests and heterogeneity in disease course and treatment response, all contribute to widespread differences in success rates on timely diagnosis and optimal treatment. We aim to provide a practical overview and guidance on relevant diagnostic and management strategies, including pitfalls and present a summary of the relevant novel developments in this field.
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Affiliation(s)
- Hendrik Stephan Goedee
- Brain Center UMC Utrecht, Department of Neurology & Neurosurgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, Department of Neurology, University Hospitals Birmingham, Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
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47
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Mesin L, Lingua E, Cocito D. Motor Nerve Conduction Block Estimation in Demyelinating Neuropathies by Deconvolution. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 9:bioengineering9010023. [PMID: 35049732 PMCID: PMC8773146 DOI: 10.3390/bioengineering9010023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 01/10/2023]
Abstract
A deconvolution method is proposed for conduction block (CB) estimation based on two compound muscle action potentials (CMAPs) elicited by stimulating a nerve proximal and distal to the region in which the block is suspected. It estimates the time delay distributions by CMAPs deconvolution, from which CB is computed. The slow afterwave (SAW) is included to describe the motor unit potential, as it gives an important contribution in case of the large temporal dispersion (TD) often found in patients. The method is tested on experimental signals obtained from both healthy subjects and pathological patients, with either Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) or Multifocal Motor Neuropathy (MMN). The new technique outperforms the clinical methods (based on amplitude and area of CMAPs) and a previous state-of-the-art deconvolution approach. It compensates phase cancellations, allowing to discriminate among CB and TD: estimated by the methods of amplitude, area and deconvolution, CB showed a correlation with TD equal to 39.3%, 29.5% and 8.2%, respectively. Moreover, a significant decrease of percentage reconstruction errors of the CMAPs with respect to the previous deconvolution approach is obtained (from a mean/median of 19.1%/16.7% to 11.7%/11.2%). Therefore, the new method is able to discriminate between CB and TD (overcoming the important limitation of clinical approaches) and can approximate patients’ CMAPs better than the previous deconvolution algorithm. Then, it appears to be promising for the diagnosis of demyelinating polyneuropathies, to be further tested in the future in a prospective clinical trial.
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Affiliation(s)
- Luca Mesin
- Mathematical Biology and Physiology, Department Electronics and Telecommunications, Politecnico di Torino, 10129 Turin, Italy;
- Correspondence: ; Tel.: +39-0110-904-085
| | - Edoardo Lingua
- Mathematical Biology and Physiology, Department Electronics and Telecommunications, Politecnico di Torino, 10129 Turin, Italy;
| | - Dario Cocito
- S.C. Neurologia I, Dipartimento di Neuroscienze, Universitá di Torino, 10124 Torino, Italy;
- I.R.C.C.S. Istituti Clinici Scientifici, Fondazione S. Maugeri, 27100 Pavia, Italy
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48
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van Rosmalen MHJ, Froeling M, Mandija S, Hendrikse J, van der Pol WL, Stephan Goedee H. MRI of the intraspinal nerve roots in patients with chronic inflammatory neuropathies: abnormalities correlate with clinical phenotypes. J Neurol 2022; 269:3159-3166. [PMID: 34988617 DOI: 10.1007/s00415-021-10864-4] [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: 12/23/2020] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN) are caused by inflammatory changes of peripheral nerves. It is unknown if the intra-spinal roots are also affected. This MRI study systematically visualized intra-spinal nerve roots, i.e., the ventral and dorsal roots, in patients with CIDP, MMN and motor neuron disease (MND). METHODS We performed a cross-sectional study in 40 patients with CIDP, 27 with MMN and 34 with MND. All patients underwent an MRI scan of the cervical intra-spinal roots. We systematically measured intra-spinal nerve root sizes bilaterally in the transversal plane at C5, C6 and C7 level. We calculated mean nerve root sizes and compared them between study groups and between different clinical phenotypes using a univariate general linear model. RESULTS Patients with MMN and CIDP with a motor phenotype had thicker ventral roots compared to patients with CIDP with a sensorimotor phenotype (p = 0.012), while patients with CIDP with a sensory phenotype had thicker dorsal roots compared to patients with a sensorimotor phenotype (p = 0.001) and with MND (p = 0.004). CONCLUSION We here show changes in the morphology of intra-spinal nerve roots in patients with chronic inflammatory neuropathies, compatible with their clinical phenotype.
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Affiliation(s)
- Marieke H J van Rosmalen
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3508GA, Utrecht, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3508GA, Utrecht, The Netherlands
| | - Martijn Froeling
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3508GA, Utrecht, The Netherlands
| | - Stefano Mandija
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3508GA, Utrecht, The Netherlands.,Computational Imaging Group for MR Diagnostic and Therapy, University Medical Center Utrecht, Heidelberglaan 100, 3508GA, Utrecht, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3508GA, Utrecht, The Netherlands
| | - W Ludo van der Pol
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3508GA, Utrecht, The Netherlands.
| | - H Stephan Goedee
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Heidelberglaan 100, 3508GA, Utrecht, The Netherlands
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49
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Hamada Y, Kanbayashi T, Takahashi K, Kamiya H, Kobayashi S, Sonoo M. Weak shoulder and arm sparing signs in amyotrophic lateral sclerosis. Muscle Nerve 2021; 65:311-316. [PMID: 34952966 DOI: 10.1002/mus.27480] [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: 10/06/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION/AIMS A number of signs of selective involvement have been reported in amyotrophic lateral sclerosis (ALS). In this study, we describe two new ones, "weak shoulder" and "arm sparing" signs. METHODS Subjects were retrospectively identified from our electrodiagnosis database. Medical Research Council scores of relevant muscles were evaluated. Weak shoulder was defined as the deltoid (Del) muscle being weaker than the biceps brachii (BB)/ triceps brachii (TB) muscles, i.e. Del was weaker than either or both of the two muscles and no stronger than either. Arm sparing was defined as both Del and the first dorsal interosseous (FDI) being weaker than BB/TB. Sensitivities of these signs were compared with other signs of selective involvement. The specificities of these signs were investigated in patients with cervical spondylotic amyotrophy (CSA) and multifocal motor neuropathy (MMN). RESULTS We reviewed 130 patients with ALS, 64 patients with CSA, and 16 patients with MMN. The weak shoulder and the arm sparing signs were observed in 73% and 55% of patients with ALS, 44% and 2% of patients with CSA (93% and 0% of patients with proximal CSA), respectively, and no patients with MMN. The sensitivity of the weak shoulder was higher than conventional signs, whereas that of the arm sparing sign was no different from them. DISCUSSION The weak shoulder sign was highly sensitive in ALS, and was specific in comparison with MMN. The arm sparing sign was highly specific for ALS. The two new signs are promising as clinical clues to diagnosing ALS.
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Affiliation(s)
- Yuichi Hamada
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
| | | | - Kazusa Takahashi
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan.,Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Hisao Kamiya
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
| | - Shunsuke Kobayashi
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
| | - Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
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50
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Keh RYS, Selby DA, Jones S, Gosal D, Lavin T, Lilleker JB, Carr AS, Lunn MP. Predicting long-term trends in inflammatory neuropathy outcome measures using latent class modelling. J Peripher Nerv Syst 2021; 27:84-93. [PMID: 34936164 DOI: 10.1111/jns.12481] [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: 11/26/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Immunoglobulin (Ig) is used to treat chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and multifocal motor neuropathy with conduction block (MMNCB). Regular infusions may be used for symptom control. Disease activity is monitored with clinical outcome measurements. We examined outcome measure variation during clinically stable periods in Ig-treated CIDP and MMNCB patients. We explored utility of serial outcome measurement in long-term outcome prediction. METHODS Retrospective longitudinal analysis of a single neuroscience centre's Ig-treated CIDP and MMNCB patients, 2009-2020, was performed. Mean and percentage change for grip strength, Rasch-built overall disability scales (RODS) and MRC sum scores (MRC-SS) during periods of clinical stability were compared to score-specific minimal clinically important differences (MCID). Latent class mixed modelling (LCMM) was used to identify longitudinal trends and factors influencing long-term outcome. RESULTS We identified 85 CIDP and 23 MMNCB patients (1,423 datapoints; 5635 treatment-months). Group-averaged outcome measures varied little over time. Intra-individual variation exceeded MCID for RODS in 44.2% CIDP and 16.7% MMNCB datapoints, grip strength in 10.6% (CIDP) and 8.8%/27.2% (MMNCB right/left hand) and MRC-SS in 43.5% (CIDP) and 20% (MMNCB). Multivariate LCMM identified subclinical trends toward improvement (32 patients) and deterioration (73 patients) in both cohorts. At baseline, CIDP 'deteriorators' were older than 'improvers' (66.2 versus 57 years, p=0.025). No other individual factors predicted categorisation. The best model for 'deteriorator' identification was contiguous sub-MCID decline in more than one outcome measure (CIDP: sensitivity 74%, specificity 59%; MMNCB: sensitivity 73%, specificity 88%). DISCUSSION Outcome measure interpretation determines therapeutic decision-making in Ig-dependent neuropathy patients, but intra-individual variation is common, often exceeding MCID. Here we show sub-MCID contiguous changes in more than one outcome measurement are a better predictor of long-term outcome. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ryan Yann Shern Keh
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK.,MRC Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Antony Selby
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester, UK
| | - Sam Jones
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - David Gosal
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Timothy Lavin
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - James B Lilleker
- Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Manchester, UK.,Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester, UK
| | - Aisling S Carr
- MRC Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael P Lunn
- MRC Centre for Neuromuscular Diseases, National Hospital of Neurology and Neurosurgery, Queen Square, University College London Hospitals NHS Foundation Trust, London, UK.,Institute of Neurology, University College London, London, UK
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