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Pascual-Goñi E, Caballero-Ávila M, Querol L. Antibodies in Autoimmune Neuropathies: What to Test, How to Test, Why to Test. Neurology 2024; 103:e209725. [PMID: 39088795 PMCID: PMC11319070 DOI: 10.1212/wnl.0000000000209725] [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: 02/29/2024] [Accepted: 05/28/2024] [Indexed: 08/03/2024] Open
Abstract
Autoimmune neuropathies are a heterogeneous group of immune-mediated disorders of the peripheral nerves. Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are the archetypal acute and chronic forms. Over the past few decades, pathogenic antibodies targeting antigens of the peripheral nervous system and driving peripheral nerve damage in selected patients have been described. Moreover, the detection of these antibodies has diagnostic and therapeutic implications that have prompted a modification of the GBS and CIDP diagnostic algorithms. GBS diagnosis is based in clinical criteria, and systematic testing of anti-ganglioside antibodies is not required. Nonetheless, a positive anti-ganglioside antibody test may support the clinical suspicion when diagnosis of GBS (GM1 IgG), Miller Fisher (GQ1b IgG), or acute sensory-ataxic (GD1b IgG) syndromes is uncertain. Anti-myelin-associated glycoprotein (MAG) IgM and anti-disialosyl IgM antibodies are key in the diagnosis of anti-MAG neuropathy and chronic ataxic neuropathy, ophthalmoplegia, M-protein, cold agglutinins, and disialosyl antibodies spectrum neuropathies, respectively, and help differentiating these conditions from CIDP. Recently, the field has been boosted by the discovery of pathogenic antibodies targeting proteins of the node of Ranvier contactin-1, contactin-associated protein 1, and nodal and paranodal isoforms of neurofascin (NF140, NF186, or NF155). These antibodies define subgroups of patients with specific clinical (most importantly poor or partial response to conventional therapies and excellent response to anti-CD20 therapy) and pathologic (node of Ranvier disruption in the absence of inflammation) features that led to the definition of the "autoimmune nodopathy" diagnostic category and to the incorporation of nodal/paranodal antibodies to clinical routine testing. The purpose of this review was to provide a practical vision for the general neurologist of the use of antibodies in the clinical assessment of autoimmune neuropathies.
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Affiliation(s)
- Elba Pascual-Goñi
- From the Neuromuscular Diseases Unit (E.P.-G., M.C.-Á., L.Q.), Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona; ERN (European Reference Network) EURO-NMD (Neuromuscular Disorders); and Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (E.P.-G., L.Q.), Madrid, Spain
| | - Marta Caballero-Ávila
- From the Neuromuscular Diseases Unit (E.P.-G., M.C.-Á., L.Q.), Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona; ERN (European Reference Network) EURO-NMD (Neuromuscular Disorders); and Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (E.P.-G., L.Q.), Madrid, Spain
| | - Luis Querol
- From the Neuromuscular Diseases Unit (E.P.-G., M.C.-Á., L.Q.), Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona; ERN (European Reference Network) EURO-NMD (Neuromuscular Disorders); and Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER) (E.P.-G., L.Q.), Madrid, Spain
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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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Collet R, Caballero-Ávila M, Querol L. Clinical and pathophysiological implications of autoantibodies in autoimmune neuropathies. Rev Neurol (Paris) 2023; 179:831-843. [PMID: 36907709 DOI: 10.1016/j.neurol.2023.02.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 03/13/2023]
Abstract
Autoimmune neuropathies are a heterogeneous group of rare and disabling diseases in which the immune system targets peripheral nervous system antigens and that respond to immune therapies. This review focuses on Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, polyneuropathy associated with IgM monoclonal gammopathy, and autoimmune nodopathies. Autoantibodies targeting gangliosides, proteins in the node of Ranvier, and myelin-associated glycoprotein have been described in these disorders, defining subgroups of patients with similar clinical features and response to therapy. This topical review describes the role of these autoantibodies in the pathogenesis of autoimmune neuropathies and their clinical and therapeutic importance.
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Affiliation(s)
- R Collet
- Department of Neurology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - M Caballero-Ávila
- Department of Neurology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - L Querol
- Department of Neurology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro para la Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Madrid, Spain.
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Acute Ascending Sensory Neuropathy Associated With Severe Acute Respiratory Syndrome Coronavirus 2 Disease. J Clin Neuromuscul Dis 2022; 23:168-169. [PMID: 35188921 DOI: 10.1097/cnd.0000000000000361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Gutierrez J, Palma JA, Kaufmann H. Acute Sensory and Autonomic Neuronopathy: A Devastating Disorder Affecting Sensory and Autonomic Ganglia. Semin Neurol 2020; 40:580-590. [PMID: 32906171 DOI: 10.1055/s-0040-1713843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Acute-onset and severe sensory and autonomic deficits with no motor dysfunction, typically preceded by a febrile illness, with poor recovery, and often fatal outcome are the hallmark features of acute sensory and autonomic neuronopathy (ASANN). Pathologically and electrophysiologically, ASANN is characterized by an extensive ganglionopathy affecting sensory and autonomic ganglia with preservation of motor neurons. Consequently, patients, usually children or young adult, develop acute-onset profound widespread loss of all sensory modalities resulting in automutilations, as well as autonomic failure causing neurogenic orthostatic hypotension, neurogenic underactive bladder, and gastroparesis and constipation. The diagnosis is clinical with support of nerve conduction studies and autonomic testing, as well as spinal cord magnetic resonance imaging showing characteristic posterior cord hyperintensities. Although the presumed etiology is immune-mediated, further studies are required to clarify the physiopathology of the disease. We here performed a systematic review of the epidemiology, pathophysiology, diagnosis, and management of ASANN, with three representative cases that recently presented at our clinic. All three patients had the typical clinical manifestations of ASANN but in different combinations, illustrating the variable phenotype of the disorder. Immunosuppression is seldom effective. Management options are limited to supportive and symptomatic care with the goal of minimizing complications and preventing death.
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Affiliation(s)
- Joel Gutierrez
- Department of Clinical Neurophysiology, Institute of Neurology and Neurosurgery, Havana, Cuba
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York
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Martín-Aguilar L, Pascual-Goñi E, Querol L. Autoantibodies in immune-mediated inflammatory neuropathies. Med Clin (Barc) 2019; 153:360-367. [PMID: 31443948 DOI: 10.1016/j.medcli.2019.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/30/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022]
Abstract
Inflammatory neuropathies are a rare and heterogeneous group of diseases of the nervous system characterized by the dysfunction and damage of different structures of the peripheral nerves. This group includes Guillain-Barré syndrome, chronic demyelinating inflammatory polyradiculoneuropathy, multifocal motor neuropathy or neuropathies associated with monoclonal gammopathy. The aetiology of these diseases is unknown, but B cells and autoantibodies play a key role in their pathogenesis. Autoantibodies against peripheral nerve molecules such as gangliosides, proteins of the Ranvier node or myelin-associated glycoprotein have been described, allowing the identification of subgroups of patients with specific clinical phenotypes. For all these reasons, these antibodies are useful in clinical practice. This review focuses on the diagnostic and therapeutic relevance of autoantibodies in inflammatory neuropathies.
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Affiliation(s)
- Lorena Martín-Aguilar
- Unidad de Enfermedades Neuromusculares, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Elba Pascual-Goñi
- Unidad de Enfermedades Neuromusculares, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Luis Querol
- Unidad de Enfermedades Neuromusculares, Hospital de la Santa Creu i Sant Pau, Barcelona, España.
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Abstract
Sensory polyneuropathies, which are caused by dysfunction of peripheral sensory nerve fibers, are a heterogeneous group of disorders that range from the common diabetic neuropathy to the rare sensory neuronopathies. The presenting symptoms, acuity, time course, severity, and subsequent morbidity vary and depend on the type of fiber that is affected and the underlying cause. Damage to small thinly myelinated and unmyelinated nerve fibers results in neuropathic pain, whereas damage to large myelinated sensory afferents results in proprioceptive deficits and ataxia. The causes of these disorders are diverse and include metabolic, toxic, infectious, inflammatory, autoimmune, and genetic conditions. Idiopathic sensory polyneuropathies are common although they should be considered a diagnosis of exclusion. The diagnostic evaluation involves electrophysiologic testing including nerve conduction studies, histopathologic analysis of nerve tissue, serum studies, and sometimes autonomic testing and cerebrospinal fluid analysis. The treatment of these diseases depends on the underlying cause and may include immunotherapy, mitigation of risk factors, symptomatic treatment, and gene therapy, such as the recently developed RNA interference and antisense oligonucleotide therapies for transthyretin familial amyloid polyneuropathy. Many of these disorders have no directed treatment, in which case management remains symptomatic and supportive. More research is needed into the underlying pathophysiology of nerve damage in these polyneuropathies to guide advances in treatment.
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Affiliation(s)
- Kelly Graham Gwathmey
- Virginia Commonwealth University, Department of Neurology, 1101 E. Marshall Street, PO Box 980599, Richmond, VA 23298, USA
| | - Kathleen T Pearson
- Virginia Commonwealth University, Department of Neurology, 1101 E. Marshall Street, PO Box 980599, Richmond, VA 23298, USA
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Guillain–Barré syndrome subtypes: A clinical electrophysiological study of 100 patients. Rev Neurol (Paris) 2019; 175:73-80. [DOI: 10.1016/j.neurol.2018.01.379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 01/24/2018] [Accepted: 01/26/2018] [Indexed: 11/22/2022]
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Debs R, Reach P, Cret C, Demeret S, Saheb S, Maisonobe T, Viala K. A new treatment regimen with high-dose and fractioned immunoglobulin in a special subgroup of severe and dependent CIDP patients. Int J Neurosci 2016; 127:864-872. [PMID: 27918219 DOI: 10.1080/00207454.2016.1269328] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyneuropathy (CIDP) is treated with intravenous immunoglobulins (IVIg), corticosteroids or plasma exchange (PE). IVIg dosage is not universal and markers for treatment management are needed. METHODS We report the response to high-dose and fractioned IVIg in a subgroup of definite CIDP patients, resistant to corticosteroids and PE, responders to IVIg but with an efficacy window <15 d. RESULTS Four patients were included with similar predominantly clinical motor form and conduction abnormalities. Treatment management consisted of fractioning IVIg and increasing the monthly cumulated dose (mean: 3 g/kg/month). Serum IgG concentration was measured and correlated to the clinical state. Monitoring of serum IgG helped to guide IVIg administration dosage and frequency. A mean of 10 months was required to improve symptoms; therapy was then switched to subcutaneous (SC) route (maintenance dose: 3.5 g/kg/month). The mean Overall Neuropathy Limitations Scale was improved from 11 to 3.2 and the mean Medical Research Council scale from 26 to 90. CONCLUSION It is important to distinguish patients with short IVIg efficacy window from those with classical resistance since the former may benefit from fractioning and increasing the IVIg dose. The monitoring of serum IgG level and its correlation to the clinical response could be of help in monitoring each individual's dosage.
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Affiliation(s)
- Rabab Debs
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Pauline Reach
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Corina Cret
- b Neurology Department , Centre Hospitalier de Meaux , Meaux , France
| | - Sophie Demeret
- c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Samir Saheb
- d Centre Clinique d'Hémobiothérapie, service d'Hématologie , Groupe Hospitalier Pitié-Salpêtrière , AP-HP , Paris , France
| | - Thierry Maisonobe
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
| | - Karine Viala
- a Département de Neurophysiologie , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France.,c Service de neurologie 1, Centre diagnostique et thérapeutique des neuropathies périphériques , Groupe Hospitalier Pitié-Salpêtriére , AP-HP , Paris , France
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Yuki N, Uncini A. Acute and chronic ataxic neuropathies with disialosyl antibodies: A continuous clinical spectrum and a common pathophysiological mechanism. Muscle Nerve 2014; 49:629-35. [DOI: 10.1002/mus.24192] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Nobuhiro Yuki
- Department of Medicine; Yong Loo Lin School of Medicine; National University of Singapore; Unit 09-01, 14 Medical Drive 117599 Singapore
| | - Antonino Uncini
- Department of Neuroscience and Imaging; University “G. d'Annunzio”; Chieti-Pescara Italy
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Autonomic manifestations in acute sensory ataxic neuropathy: a case report. Auton Neurosci 2013; 179:155-8. [PMID: 23598285 DOI: 10.1016/j.autneu.2013.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 02/20/2013] [Accepted: 03/25/2013] [Indexed: 11/23/2022]
Abstract
Acute sensory ataxic neuropathy (ASAN) is known to occur with acute and monophasic sensory ataxia. Although autonomic dysfunctions have been reported, no detailed descriptions are currently available. We describe a case of ASAN in which the autonomic manifestations were systematically investigated. Although the patient did not complain of any autonomic symptoms, except for photophobia due to mydriasis, autonomic testing revealed widespread autonomic dysfunctions. Norepinephrine and dobutamine infusion test indicated the presence of sympathetic dysfunction. Additionally, the pupillary response to pilocarpine revealed the presence of parasympathetic dysfunction. In conclusion, widespread, subclinical autonomic dysfunctions may be present in ASAN patients.
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