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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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2
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Liu Y, Dong M, Chu Y, Zhou L, You Y, Pang X, Yang S, Zhang L, Chen L, Zhu L, Xiao J, Wang W, Qin C, Tian D. Dawn of CAR-T cell therapy in autoimmune diseases. Chin Med J (Engl) 2024; 137:1140-1150. [PMID: 38613216 PMCID: PMC11101238 DOI: 10.1097/cm9.0000000000003111] [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: 12/18/2023] [Indexed: 04/14/2024] Open
Abstract
ABSTRACT Chimeric antigen receptor (CAR)-T cell therapy has achieved remarkable success in the treatment of hematological malignancies. Based on the immunomodulatory capability of CAR-T cells, efforts have turned toward exploring their potential in treating autoimmune diseases. Bibliometric analysis of 210 records from 128 academic journals published by 372 institutions in 40 countries/regions indicates a growing number of publications on CAR-T therapy for autoimmune diseases, covering a range of subtypes such as systemic lupus erythematosus, multiple sclerosis, among others. CAR-T therapy holds promise in mitigating several shortcomings, including the indiscriminate suppression of the immune system by traditional immunosuppressants, and non-sustaining therapeutic levels of monoclonal antibodies due to inherent pharmacokinetic constraints. By persisting and proliferating in vivo , CAR-T cells can offer a tailored and precise therapeutics. This paper reviewed preclinical experiments and clinical trials involving CAR-T and CAR-related therapies in various autoimmune diseases, incorporating innovations well-studied in the field of hematological tumors, aiming to explore a safe and effective therapeutic option for relapsed/refractory autoimmune diseases.
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Affiliation(s)
- Yuxin Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Minghao Dong
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yunhui Chu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Luoqi Zhou
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yunfan You
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Xiaowei Pang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Sheng Yang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Luyang Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Lian Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Lifang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Jun Xiao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Wei Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Chuan Qin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Daishi Tian
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
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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 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 Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Luca Gentile
- Department of Clinical and Experimental Medicine, Unit of Neurology, University of Messina, Messina, Italy
| | - Dario Cocito
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Raffaella Fazio
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Milano, Italy
| | - Marco Luigetti
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, Roma, Italy
- Università Cattolica del Sacro Cuore, Sede di Roma, Roma, Italy
| | - Chiara Briani
- Neurology Unit, Department of Neuroscience, University of Padova, Padova, Italy
| | - Massimiliano Filosto
- Department of Clinical and Experimental Sciences, University of Brescia; NeMO-Brescia Clinical center for Neuromuscular Diseases, Brescia, Italy
| | - Gabriele Siciliano
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Giovanni Antonini
- Unit of Neurophysiopathology, Department of Neurology Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sant'Andrea Hospital, Sapienza' University of Rome, Roma, Italy
| | - Sabrina Matà
- Department of Neurological and Psychiatric Sciences, Azienda Ospedaliero-Universitaria di Careggi, Florence, Italy
| | - Girolama Alessandra Marfia
- Dysimmune Neuropathies Unit, Department of Systems Medicine, Tor Vergata University of Rome, Roma, Italy
| | - Maurizio Inghilleri
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
- IRCCS Neuromed, Pozzilli, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples 'Federico II', Napoli, Italy
| | - Giuseppe Cosentino
- Department of Brain and Behavioral Sciences, IRCCS Mondino Foundation, University of Pavia, Pavia, Italy
| | - Filippo Brighina
- Azienda Ospedaliera Universitaria Policlinico Paolo Giaccone, Palermo, Italy
| | | | - Francesca Carta
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Anna Mazzeo
- Department of Clinical and Experimental Medicine, Unit of Neurology, University of Messina, Messina, Italy
| | - Erdita Peci
- Presidio Sanitario Major, Istituti Clinici Scientifici Maugeri, Torino, Italy
| | - Camilla Strano
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), San Raffaele Scientific Institute, Milano, Italy
| | - Angela Romano
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, UOC Neurologia, Roma, Italy
- Università Cattolica del Sacro Cuore, Sede di Roma, Roma, Italy
| | - Marta Campagnolo
- Neurology Unit, Department of Neuroscience, University of Padova, Padova, Italy
| | - Stefano Cotti-Piccinelli
- Department of Clinical and Experimental Sciences, University of Brescia; NeMO-Brescia Clinical center for Neuromuscular Diseases, Brescia, Italy
| | - Divina Valeria Viola
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Luca Leonardi
- Unit of Neurophysiopathology, Department of Neurology Mental Health and Sensory Organs (NESMOS), Faculty of Medicine and Psychology, Sant'Andrea Hospital, Sapienza' University of Rome, Roma, Italy
| | - Martina Sperti
- Department of Neurological and Psychiatric Sciences, Azienda Ospedaliero-Universitaria di Careggi, Florence, Italy
| | - Giorgia Mataluni
- Dysimmune Neuropathies Unit, Department of Systems Medicine, Tor Vergata University of Rome, Roma, Italy
| | - Marco Ceccanti
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Emanuele Spina
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples 'Federico II', Napoli, Italy
| | - Elisa Vegezzi
- Department of Brain and Behavioral Sciences, IRCCS Mondino Foundation, University of Pavia, Pavia, Italy
| | - Vincenzo Di Stefano
- Azienda Ospedaliera Universitaria Policlinico Paolo Giaccone, Palermo, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Medical Biotechnology and Translational Medicine, Milan University, Milano, Italy
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4
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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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5
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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 DOI: 10.1111/ene.16202] [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: 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 Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Li
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jingwen Niu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Hu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jianfeng Ding
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Liying Cui
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Mingsheng Liu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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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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7
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Kuwahara M. [Prospect of novel therapies in immune-mediated neuropathies]. Rinsho Shinkeigaku 2024; 64:1-7. [PMID: 38072443 DOI: 10.5692/clinicalneurol.cn-001888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
The efficacy of immunotherapies such as steroids, plasmapheresis, and intravenous immunoglobulin have been proven in various immune-mediated neuropathies. However, these treatments sometimes lack the efficacy in a part of patients with the immune-mediated neuropathies. In addition, anti-myelin associated glycoprotein (MAG) neuropathy is usually refractory to the treatments. Recently, novel therapies targeting a molecule which are associated with pathogenesis of immune-mediated diseases, have been developed. These molecularly targeted therapies are notable in immune-mediated neuropathies as novel drug candidates. In the present article, current treatments and future prospect of novel therapies in immune-mediated neuropathies will be reviewed.
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Affiliation(s)
- Motoi Kuwahara
- Department of Neurology, Kindai University Faculty of Medicine
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8
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Vazquez Do Campo R, Dyck PJB. Focal inflammatory neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:273-290. [PMID: 38697745 DOI: 10.1016/b978-0-323-90108-6.00009-0] [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
This chapter focuses on neuropathies that present with focal involvement of nerve roots, plexus, and/or peripheral nerves associated with autoimmune and inflammatory mechanisms that present with focal involvement of nerve roots, plexus and/or peripheral nerves. The clinical presentation, diagnosis, and treatment of focal autoimmune demyelinating neuropathies, focal nonsystemic vasculitic disorders (diabetic and nondiabetic radiculoplexus neuropathies, postsurgical inflammatory neuropathy, and neuralgic amyotrophy), and focal neuropathies associated with sarcoidosis and bacterial and viral infections are reviewed.
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Affiliation(s)
- Rocio Vazquez Do Campo
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - P James B Dyck
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, MN, United States; Peripheral Neuropathy Research Laboratory, Mayo Clinic, Rochester, MN, United States.
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9
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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: 0] [Impact Index Per Article: 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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10
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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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11
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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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12
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Tomkins O, Leblond V, Lunn MP, Viala K, Weil DR, D'Sa S. Investigation and Management of Immunoglobulin M- and Waldenström-Associated Peripheral Neuropathies. Hematol Oncol Clin North Am 2023; 37:761-776. [PMID: 37385714 DOI: 10.1016/j.hoc.2023.04.007] [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: 07/01/2023]
Abstract
The immunoglobulin M (IgM)-associated peripheral neuropathies (PN) are a heterogeneous group of disorders representing most paraproteinemic neuropathy cases. They are associated with IgM monoclonal gammopathy of undetermined significance (MGUS) or Waldenström macroglobulinemia. Establishing a causal link between a paraprotein and neuropathy can be challenging but is necessary to adopt an appropriate therapeutic approach. The most common type of IgM-PN is Antimyelin-Associated-Glycoprotein neuropathy, but half of the cases are of other causes. Progressive functional impairment is an indication for treatment, even when the underlying disorder is IgM MGUS, involving either rituximab monotherapy or combination chemotherapy to achieve clinical stabilization.
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Affiliation(s)
- Oliver Tomkins
- Department of Haematology, Centre for Waldenströms Macroglobulinaemia and Related Conditions, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK. https://twitter.com/tomkinsoliver
| | - Veronique Leblond
- Department of Haematology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Michael P Lunn
- National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Karine Viala
- Department of Clinical Neurophysiology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Damien Roos Weil
- Department of Haematology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Shirley D'Sa
- Department of Haematology, Centre for Waldenströms Macroglobulinaemia and Related Conditions, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
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13
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Dziadkowiak E, Nowakowska-Kotas M, Rałowska-Gmoch W, Budrewicz S, Koszewicz M. Molecular, Electrophysiological, and Ultrasonographic Differences in Selected Immune-Mediated Neuropathies with Therapeutic Implications. Int J Mol Sci 2023; 24:ijms24119180. [PMID: 37298132 DOI: 10.3390/ijms24119180] [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: 03/31/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023] Open
Abstract
The spectrum of immune-mediated neuropathies is broad and the different subtypes are still being researched. With the numerous subtypes of immune-mediated neuropathies, establishing the appropriate diagnosis in normal clinical practice is challenging. The treatment of these disorders is also troublesome. The authors have undertaken a literature review of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), Guillain-Barre syndrome (GBS) and multifocal motor neuropathy (MMN). The molecular, electrophysiological and ultrasound features of these autoimmune polyneuropathies are analyzed, highlighting the differences in diagnosis and ultimately treatment. The immune dysfunction can lead to damage to the peripheral nervous system. In practice, it is suspected that these disorders are caused by autoimmunity to proteins located in the node of Ranvier or myelin components of peripheral nerves, although disease-associated autoantibodies have not been identified for all disorders. The electrophysiological presence of conduction blocks is another important factor characterizing separate subgroups of treatment-naive motor neuropathies, including multifocal CIDP (synonyms: multifocal demyelinating neuropathy with persistent conduction block), which differs from multifocal motor neuropathy with conduction block (MMN) in both responses to treatment modalities and electrophysiological features. Ultrasound is a reliable method for diagnosing immune-mediated neuropathies, particularly when alternative diagnostic examinations yield inconclusive results. In overall terms, the management of these disorders includes immunotherapy such as corticosteroids, intravenous immunoglobulin or plasma exchange. Improvements in clinical criteria and the development of more disease-specific immunotherapies should expand the therapeutic possibilities for these debilitating diseases.
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Affiliation(s)
- Edyta Dziadkowiak
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Marta Nowakowska-Kotas
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Wiktoria Rałowska-Gmoch
- Department of Neurology, The St. Jadwiga's Regional Specialist Neuropsychiatric Centre, Wodociągowa 4, 45-221 Opole, Poland
| | - Sławomir Budrewicz
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Magdalena Koszewicz
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
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14
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Al-Zamil M, Shnayder NA, Davydova TK, Nasyrova RF, Trefilova VV, Narodova EA, Petrova MM, Romanova IV, Chumakova GA. Amyotrophic Lateral Sclerosis Mimic Syndrome in a 24-Year-Old Man with Chiari 1 Malformation and Syringomyelia: A Clinical Case. J Clin Med 2023; 12:jcm12082932. [PMID: 37109269 PMCID: PMC10143794 DOI: 10.3390/jcm12082932] [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: 02/24/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Chiari 1 Malformation (CM1) is classically defined as a caudal displacement of the cerebellar tonsils through the foramen magnum into the spinal cord. Modern imaging techniques and experimental studies disclose a different etiology for the development of CM1, but the main etiology factor is a structural defect in the skull as a deformity or partial reduction, which push down the lower part of the brain and cause the cerebellum to compress into the spinal canal. CM1 is classified as a rare disease. CM1 can present with a wide variety of symptoms, also non-specific, with consequent controversies on diagnosis and surgical decision-making, particularly in asymptomatic or minimally symptomatic. Other disorders, such as syringomyelia (Syr), hydrocephalus, and craniocervical instability can be associated at the time of the diagnosis or appear secondarily. Therefore, CM1-related Syr is defined as a single or multiple fluid-filled cavities within the spinal cord and/or the bulb. A rare CM1-related disorder is syndrome of lateral amyotrophic sclerosis (ALS mimic syndrome). We present a unique clinical case of ALS mimic syndrome in a young man with CM1 and a huge singular syringomyelic cyst with a length from segment C2 to Th12. At the same time, the clinical picture showed upper hypotonic-atrophic paraparesis in the absence of motor disorders in the lower extremities. Interestingly, this patient did not have a disorder of superficial and deep types of sensitivity. This made it difficult to diagnose CM1. For a long time, the patient's symptoms were regarded as a manifestation of ALS, as an independent neurological disease, and not as a related disorder of CM1. Surgical treatment for CM1 was not effective, but it allowed to stabilize the course of CM1-related ALS mimic syndrome over the next two years.
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Affiliation(s)
- Mustafa Al-Zamil
- Department of Physiotherapy, Faculty of Continuing Medical Education, Peoples' Friendship University of Russia, 117198 Moscow, Russia
| | - Natalia A Shnayder
- Institute of Personalized Psychiatry and Neurology, V.M. Bekhterev National Medical Research Centre for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
- Shared Core Facilities "Molecular and Cell Technologies", V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Tatiana K Davydova
- Department of Neurogenerative Disorders, Yakut Science Centre of Complex Medical Problems, 677000 Yakutsk, Russia
| | - Regina F Nasyrova
- Institute of Personalized Psychiatry and Neurology, V.M. Bekhterev National Medical Research Centre for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
| | | | - Ekaterina A Narodova
- Shared Core Facilities "Molecular and Cell Technologies", V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Marina M Petrova
- Shared Core Facilities "Molecular and Cell Technologies", V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Irina V Romanova
- Shared Core Facilities "Molecular and Cell Technologies", V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Galina A Chumakova
- Department of Therapy and General Medical Practice with a Course of Postgraduate Professional Education, Altai State Medical University, 656038 Barnaul, Russia
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15
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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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16
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Herrmann C, Dorst J. Differenzialdiagnose der Amyotrophen Lateralsklerose in der
klinischen Praxis. KLIN NEUROPHYSIOL 2023. [DOI: 10.1055/a-2012-2736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
ZusammenfassungDie Diagnose der Amyotrophen Lateralsklerose (ALS) beruht vorwiegend auf
klinischen Kriterien und kann aufgrund des heterogenen Erscheinungsbildes gerade
in frühen Krankheitsstadien mitunter schwierig sein. Wegweisend sind der
Nachweis einer kombinierten Pathologie des oberen und unteren Motoneurons, der
fokale Onset, das Ausbreitungsmuster (Spreading), das typische Verteilungsmuster
der Paresen, das Vorhandensein oder Fehlen nicht-motorischer Zusatzsymptome
sowie Art und Geschwindigkeit der Krankheitsprogredienz. Dieser Review stellt
Charakteristika der ALS sowohl im Hinblick auf die klinische Untersuchung als
auch apparativer Zusatzdiagnostik in Abgrenzung zu den wichtigsten
Differenzialdiagnosen in Form von Einschlusskörperchenmyositis,
Chronisch Inflammatorischer Demyelinisierender Polyneuropathie (CIDP),
Mulifokaler Motorischer Neuropathie (MMN), adulter Form der Spinalen
Muskelatrophie (SMA), Kennedy-Syndrom und Hereditärer Spastischer
Paralyse (HSP) dar.
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17
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Hayden ME, Kim J, Arányi Z, Wolfe SW. Outcome of Tendon Transfer for Monomelic Amyotrophy (Hirayama Disease). J Hand Surg Am 2023; 48:90.e1-90.e5. [PMID: 35078694 DOI: 10.1016/j.jhsa.2021.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/15/2021] [Accepted: 11/24/2021] [Indexed: 02/02/2023]
Abstract
Hirayama disease is a motor neuron disease predominantly affecting adolescent males. The identifying feature of Hirayama disease is unilateral forearm and intrinsic muscle weakness that spares the brachioradialis, termed "oblique atrophy." Hirayama disease progresses slowly over several years, followed by an abrupt arrest. The pathognomonic finding is the anterior displacement of the cervical spinal cord with the detachment of the posterior dura. Systematic clinical evaluation and appropriate diagnostic studies are crucial to rule out a variety of compressive, immune-mediated, and genetic disorders. We present a patient with Hirayama disease whose hand function was improved dramatically by a tendon transfer after nearly 3 years without a definitive diagnosis and call attention to the hand surgeon's role in identifying this rare disease to enable timely functional restoration.
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Affiliation(s)
- Mallory E Hayden
- Department of Orthopedic Surgery, Hand and Upper Extremity, Hospital for Special Surgery, New York, NY
| | - Jinseong Kim
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Zsuzsanna Arányi
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Scott W Wolfe
- Department of Orthopedic Surgery, Hand and Upper Extremity, Hospital for Special Surgery, New York, NY.
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18
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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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19
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Sundaram S, Tandon V, Nair SS. Rituximab as Maintenance Therapy in Multifocal Motor Neuropathy: Report of Two Cases. J Clin Neuromuscul Dis 2022; 24:114-116. [PMID: 36409347 DOI: 10.1097/cnd.0000000000000412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Soumya Sundaram
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
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20
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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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21
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Min YG, Ju W, Ha YE, Ban JJ, Shin JY, Kim SM, Hong YH, Park SH, Sung JJ. Skin Biopsy as a Novel Diagnostic Aid in Immune-Mediated Neuropathies. J Neuropathol Exp Neurol 2022; 81:1018-1025. [PMID: 36137254 PMCID: PMC9677240 DOI: 10.1093/jnen/nlac085] [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] [Indexed: 01/06/2023] Open
Abstract
Immune-mediated neuropathies are a heterogenous group of inflammatory peripheral nerve disorders. They can be classified according to the domain where the autoimmune process begins: the internode, paranode, or node. However, conventional diagnostic tools, electrodiagnosis (EDX), and autoantibody testing do not fully address this issue. In this institutional cohort study, we investigated the value of dermal myelinated fiber analysis for target domain-based classification. Twenty-seven consecutive patients with immune-mediated neuropathies underwent skin biopsies. The sections were stained with antibodies representative of myelinated fiber domains and were scanned using a confocal microscope. Clinical and pathological features of each patient were reviewed comprehensively. Quantitative morphometric parameters were subjected to clustering analysis, which stratified patients into 3 groups. Cluster 1 ("internodopathy") was characterized by prominent internodal disruption, intact nodes and paranodes, demyelinating EDX pattern, and absence of nodal-paranodal antibodies. Cluster 2 ("paranodopathy") was characterized by paranodal disruption and corresponding antibodies. Morphological changes were restricted to the nodes in cluster 3; we designated this cluster as "nodopathy." This report highlights the utility of skin biopsy as a diagnostic aid to gain pathogenic insight and classify patients with immune-mediated neuropathies.
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Affiliation(s)
- Young Gi Min
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea,Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Woohee Ju
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Ye-Eun Ha
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Jae-Jun Ban
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea,Neuroscience Research Institute, Biomedical Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Je-Young Shin
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Sung-Min Kim
- From the Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Yoon-Ho Hong
- Department of Neurology, Seoul National University Seoul Metropolitan Government Boramae Hospital, Seoul, Korea
| | - Sung-Hye Park
- Department of Pathology, Seoul National University Hospital, Soul, Korea
| | - Jung-Joon Sung
- Send correspondence to: Jung-Joon Sung, MD, PhD, Department of Neurology, Seoul National University Hospital, Department of Translational Medicine, Seoul National University College of Medicine, 101 Daehangno, Jongnogu, Seoul 03080, Korea; E-mail:
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22
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Goslinga JA, Terrelonge M, Bedlack R, Barkhaus P, Barnes B, Bertorini T, Bromberg M, Carter G, Chen A, Crayle J, Dimachkie M, Jiang L, Levitsky G, Lund I, Martin S, Mcdermott C, Pattee G, Pierce K, Ratner D, Slachtova L, Sun Y, Wicks P. ALSUntangled #65: glucocorticoid corticosteroids. Amyotroph Lateral Scler Frontotemporal Degener 2022; 24:351-357. [PMID: 35997522 DOI: 10.1080/21678421.2022.2099746] [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: 11/01/2022]
Abstract
ALSUntangled reviews alternative and off-label treatments for people with amyotrophic lateral sclerosis (PALS). Here we review glucocorticoids. Neuroinflammation plays a prominent role in amyotrophic lateral sclerosis (ALS) pathogenesis, so some hypothesize that glucocorticoids might be an effective ALS therapy through their immunosuppressive effects. In this paper, we review the available evidence for glucocorticoids in ALS, including one pre-clinical study with a genetic mouse model of ALS, nine case reports (ranging from 1 to 26 patients each), and four clinical trials. We also review the possible side effects (including steroid myopathy) and the costs of therapy. We graded the level of evidence as follows: Mechanism, D; Pre-Clinical, F; Cases, B; Trials, F; Risks, C. Our review of the current evidence concludes that glucocorticoids do not offer clinical benefit in ALS and confer serious risks. Thus, ALSUntangled does not recommend glucocorticoids as a treatment for ALS.
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Affiliation(s)
- Jill Ann Goslinga
- Neurology Department, University of California San Francisco, San Francisco, CA, USA
| | - Mark Terrelonge
- Neurology Department, University of California San Francisco, San Francisco, CA, USA
| | | | - Paul Barkhaus
- Neurology Department, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benjamin Barnes
- Neurology Department, Augusta University Medical College of Georgia, Augusta, GA, USA
| | - Tulio Bertorini
- Neurology Department, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mark Bromberg
- Neurology Department, University of Utah Health, Salt Lake City, UT, USA
| | - Gregory Carter
- Physical Medicine and Rehabilitation, Saint Luke's Rehabilitation Institute, Spokane, WA, USA
| | - Amy Chen
- Neurology Department, Medical University of South Carolina, Charleston, SC, USA
| | - Jesse Crayle
- Neurology Department, Washington University, St. Louis, MO, USA
| | - Mazen Dimachkie
- Neurology Department, University of Kansas Health System, Kansas City, KS, USA
| | - Leanne Jiang
- Neuromuscular and Neurological Disorders, Perron Institute for Neurological and Translational Science, Nedlands, WA, AUS
| | | | | | - Sarah Martin
- Physical Therapy Department, Duke University, Durham, NC, USA
| | - Christopher Mcdermott
- Institute for Translational Neuroscience, The University of Sheffield, Sheffield, SY, UK
| | - Gary Pattee
- Neurology Department, University of Nebraska Medical Center, Lincoln, NE, USA
| | - Kaitlyn Pierce
- Undergraduate, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Lenka Slachtova
- Biology and Medical Genetics, Univerzita Karlova Biologicka Sekce, and
| | - Yuyao Sun
- Neurology Department, Duke University, Durham, NC, USA
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Therapies in Autoimmune Peripheral Neuropathies beyond Intravenous Immunoglobulin, Plasma Exchange and Corticosteroids: An Analytical Review. Transfus Med Rev 2022; 36:220-229. [DOI: 10.1016/j.tmrv.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 11/20/2022]
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Hatake S, Shimizu F, Honda M, Takahashi S, Koga M, Kimura K, Kanda T. [Intravenous immunoglobulin-induced eczematous eruption in autoimmune neuromuscular diseases]. Rinsho Shinkeigaku 2022; 62:267-271. [PMID: 35354723 DOI: 10.5692/clinicalneurol.cn-001681] [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: 11/05/2022]
Abstract
BACKGROUND Intravenous immunoglobulin (IVIg) have been administrated for the long time in patients with several autoimmune neuromuscular diseases. Eczematous eruption has been described as IVIg-induced adverse effect. OBJECTIVE The purpose of this study is to clarify the incidence and characteristic of IVIg-induced eczematous eruption in autoimmune neuromuscular disease. METHODS We retrospectively collected the data from 92 patients with autoimmune neuromuscular diseases, including 35 patients with chronic inflammatory demyelinating polyneuropathy (CIDP), 8 patients with multifocal motor neuropathy (MMN), 25 patients with myositis, 15 patients with Guillain-Barré syndrome (GBS), and 9 patients with myasthenia gravis (MG), who have administrated IVIg in Yamaguchi University Hospital. RESULTS There are 10 patients (6 CIDP/4 MMN), who had an eczematous skin reaction after IVIg infusion. The frequencies of IVIg-induced eczematous eruption were significantly higher in patients with multifocal acquired demyelinating sensory and motor (MADSAM) and MMN than in patients with GBS, myositis, and MG. In addition, corticosteroids or immunosuppressive drugs had been administrated before IVIg treatment more frequently in patients with myositis and MG than in those with MADSAM and MMN. CONCLUSION MADSAM or MMN patients had more frequently IVIg-induced eczematous eruption than other autoimmune neuromuscular diseases. Pathophysiology of MADAM and MMN is considered to be cell-mediated immunity against the peripheral nerve and the accumulation of IgG in both epidermis and dermis of the hand after IVIg may induce the infiltration of inflammatory cells around the vessels in the skin, causing eczematous eruption in MADSAM and MMN.
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Affiliation(s)
- Seira Hatake
- Department of Clinical Neuroscience and Neurology, Yamaguchi University Graduate School of Medicine.,Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Fumitaka Shimizu
- Department of Clinical Neuroscience and Neurology, Yamaguchi University Graduate School of Medicine
| | - Masaya Honda
- Department of Clinical Neuroscience and Neurology, Yamaguchi University Graduate School of Medicine
| | - Shiori Takahashi
- Department of Clinical Neuroscience and Neurology, Yamaguchi University Graduate School of Medicine
| | - Michiaki Koga
- Department of Clinical Neuroscience and Neurology, Yamaguchi University Graduate School of Medicine
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Takashi Kanda
- Department of Clinical Neuroscience and Neurology, Yamaguchi University Graduate School of Medicine
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Uncini A, Mathis S, Vallat JM. New classification of autoimmune neuropathies based on target antigens and involved domains of myelinated fibres. J Neurol Neurosurg Psychiatry 2022; 93:57-67. [PMID: 34373238 DOI: 10.1136/jnnp-2021-326889] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/09/2021] [Indexed: 01/23/2023]
Abstract
Autoimmune neuropathies are named by eponyms, by descriptive terminology or because of the presence of specific antibodies and are traditionally classified, on the basis of pathology and electrophysiology, as primary demyelinating or axonal. However, autoimmune disorders targeting specific molecules of the nodal region, although not showing pathological evidence of demyelination, can exhibit all the electrophysiological changes considered characteristic of a demyelinating neuropathy and acute neuropathies with antiganglioside antibodies, classified as axonal and due to nodal dysfunction, can present with reversible conduction failure and prompt recovery that appear contradictory with the common view of an axonal neuropathy. These observations bring into question the concepts of demyelinating and axonal nerve conduction changes and the groundwork of the classical dichotomous classification.We propose a classification of autoimmune neuropathies based on the involved domains of the myelinated fibre and, when known, on the antigen. This classification, in our opinion, helps to better systematise autoimmune neuropathies because points to the site and molecular target of the autoimmune attack, reconciles some contrasting pathological and electrophysiological findings, circumvents the apparent paradox that neuropathies labelled as axonal may be promptly reversible and finally avoids taxonomic confusion and possible misdiagnosis.
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Affiliation(s)
- Antonino Uncini
- Neuroscience and Imaging, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Italy
| | - Stephane Mathis
- Department of Neurology, National Reference Center for Neuromuscular Disorders, ALS Center, CHU Bordeaux (Pellegrin Hospital), Bordeaux, France
| | - Jean-Michel Vallat
- National Reference Center for Rare Peripheral Neuropathies and Department of Neurology, CHU Limoges (Dupuytren Hospital), Limoges, France
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26
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Budding K, Johansen LE, Van de Walle I, Dijkxhoorn K, de Zeeuw E, Bloemenkamp LM, Bos JW, Jansen MD, Curial CAD, Silence K, de Haard H, Blanchetot C, Van de Ven L, Leusen JHW, Pasterkamp RJ, van den Berg LH, Hack CE, Boross P, van der Pol WL. Anti-C2 Antibody ARGX-117 Inhibits Complement in a Disease Model for Multifocal Motor Neuropathy. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 9:9/1/e1107. [PMID: 34759020 PMCID: PMC8587732 DOI: 10.1212/nxi.0000000000001107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 09/10/2021] [Indexed: 11/22/2022]
Abstract
Background and Objectives To determine the role of complement in the disease pathology of multifocal motor neuropathy (MMN), we investigated complement activation, and inhibition, on binding of MMN patient-derived immunoglobulin M (IgM) antibodies in an induced pluripotent stem cell (iPSC)-derived motor neuron (MN) model for MMN. Methods iPSC-derived MNs were characterized for the expression of complement receptors and membrane-bound regulators, for the binding of circulating IgM anti-GM1 from patients with MMN, and for subsequent fixation of C4 and C3 on incubation with fresh serum. The potency of ARGX-117, a novel inhibitory monoclonal antibody targeting C2, to inhibit fixation of complement was assessed. Results iPSC-derived MNs moderately express the complement regulatory proteins CD46 and CD55 and strongly expressed CD59. Furthermore, MNs express C3aR, C5aR, and complement receptor 1. IgM anti-GM1 antibodies in serum from patients with MMN bind to MNs and induce C3 and C4 fixation on incubation with fresh serum. ARGX-117 inhibits complement activation downstream of C4 induced by patient-derived anti-GM1 antibodies bound to MNs. Discussion Binding of IgM antibodies from patients with MMN to iPSC-derived MNs induces complement activation. By expressing complement regulatory proteins, particularly CD59, MNs are protected against complement-mediated lysis. Yet, because of expressing C3aR, the function of these cells may be affected by complement activation upstream of membrane attack complex formation. ARGX-117 inhibits complement activation upstream of C3 in this disease model for MMN and therefore represents an intervention strategy to prevent harmful effects of complement in MMN.
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Affiliation(s)
- Kevin Budding
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Lill Eva Johansen
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Inge Van de Walle
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Kim Dijkxhoorn
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Elisabeth de Zeeuw
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Lauri M Bloemenkamp
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Jeroen W Bos
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Marc D Jansen
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Chantall A D Curial
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Karen Silence
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Hans de Haard
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Christophe Blanchetot
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Liesbeth Van de Ven
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Jeanette H W Leusen
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - R Jeroen Pasterkamp
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Leonard H van den Berg
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - C Erik Hack
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - Peter Boross
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands
| | - W Ludo van der Pol
- From the Center for Translational Immunology (K.B., K.D., E.Z., L.M.B., J.H.W.L., C.E.H., P.B.), University Medical Center Utrecht; Department of Neurology and Neurosurgery (L.E.J., L.M.B., J.W.B., M.D.J., C.A.D.C., L.H.B., W.L.P.), University Medical Center Utrecht Brain Center; Department of Translational Neuroscience (L.E.J., L.M.B., R.J.P.), University Medical Center Utrecht Brain Center, Utrecht University; Argenx BVBA, Industriepark-Zwijnaarde 7 (I.W., K.S., H.H., C.B., L.V.), Zwijnaarde, Belgium; and Prothix (C.E.H., P.B.), Leiden, the Netherlands.
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Beecher G, Shelly S, Dyck PJB, Mauermann ML, Martinez-Thompson JM, Berini SE, Naddaf E, Shouman K, Taylor BV, Dyck PJ, Engelstad J, Howe BM, Mills JR, Dubey D, Spinner RJ, Klein CJ. Pure Motor Onset and IgM-Gammopathy Occurrence in Multifocal Acquired Demyelinating Sensory and Motor Neuropathy. Neurology 2021; 97:e1392-e1403. [PMID: 34376509 DOI: 10.1212/wnl.0000000000012618] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/16/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To longitudinally investigate patients with multifocal acquired demyelinating sensory and motor neuropathy (MADSAM), quantifying timing and location of sensory involvements in motor onset patients, along with clinicohistopathologic and electrophysiologic findings to ascertain differences in patients with and without monoclonal gammopathy of uncertain significance (MGUS). METHODS Patients with MADSAM seen at Mayo Clinic and tested for monoclonal gammopathy and ganglioside antibodies were retrospectively reviewed (January 1, 2007-December 31, 2018). RESULTS Of 76 patients with MADSAM, 53% had pure motor, 16% pure sensory, 30% sensorimotor, and 1% cranial nerve onsets. Motor-onset patients were initially diagnosed with multifocal motor neuropathy (MMN). MGUS occurred in 25% (89% immunoglobulin M [IgM] subtype), associating with ganglioside autoantibodies (p < 0.001) and higher IgM titers (p < 0.04). Median time to sensory involvements (confirmed by electrophysiology) in motor onset patients was 18 months (range 6-180). Compared to initial motor nerve involvements, subsequent sensory findings were within the same territory in 35% (14/40), outside in 20% (8/40), or both in 45% (18/40). Brachial and lumbosacral plexus MRI was abnormal in 87% (34/39) and 84% (21/25), respectively, identifying hypertrophy and increased T2 signal predominantly in brachial plexus trunks (64%), divisions (69%), and cords (69%), and intrapelvic sciatic (64%) and femoral (44%) nerves. Proximal fascicular nerve biopsies (n = 9) more frequently demonstrated onion-bulb pathology (p = 0.001) and endoneurial inflammation (p = 0.01) than distal biopsies (n = 17). MRI and biopsy findings were similar among patient subgroups. Initial Inflammatory Neuropathy Cause and Treatment (INCAT) disability scores were higher in patients with MGUS relative to without (p = 0.02). Long-term treatment responsiveness by INCAT score reduction ≥1 or motor Neuropathy Impairment Score (mNIS) >8-point reduction occurred in 75% (49/65) irrespective of MGUS or motor onsets. Most required ongoing immunotherapy (86%). Patients with MGUS more commonly required dual-agent immunotherapy for stability (p = 0.02). DISCUSSION Pure motor onsets are the most common MADSAM presentation. Long-term follow-up, repeat electrophysiology, and nerve pathology help distinguish motor onset MADSAM from MMN. Better long-term immunotherapy responsiveness occurs in motor onset MADSAM compared to MMN reports. Patients with MGUS commonly require dual immunotherapy. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that most clinical, electrophysiologic, and histopathologic findings were similar between patients with MADSAM with and without MGUS.
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Affiliation(s)
- Grayson Beecher
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Shahar Shelly
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - P James B Dyck
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Michelle L Mauermann
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Jennifer M Martinez-Thompson
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Sarah E Berini
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Elie Naddaf
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Kamal Shouman
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Bruce V Taylor
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Peter James Dyck
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - JaNean Engelstad
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Benjamin M Howe
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - John R Mills
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Divyanshu Dubey
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Robert J Spinner
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia
| | - Christopher J Klein
- From the Departments of Neurology (G.B., S.S., P. James B. Dyck, M.L.M., J.M.M.-T., S.E.B., E.N., K.S., Peter James B. Dyck, D.D., C.J.K.), Radiology (B.M.H.), Laboratory Medicine and Pathology (P. James B. Dyck, Peter James B. Dyck, J.E., J.R.M., D.D., C.J.K.), and Neurosurgery (R.J.S.), Mayo Clinic, Rochester, MN; and Menzies Institute for Medical Research (B.V.T.), University of Tasmania, Australia.
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Sommer C, Carroll AS, Koike H, Katsuno M, Ort N, Sobue G, Vucic S, Spies JM, Doppler K, Kiernan MC. Nerve biopsy in acquired neuropathies. J Peripher Nerv Syst 2021; 26 Suppl 2:S21-S41. [PMID: 34523188 DOI: 10.1111/jns.12464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 06/02/2021] [Accepted: 08/24/2021] [Indexed: 11/29/2022]
Abstract
A diagnosis of neuropathy can typically be determined through clinical assessment and focused investigation. With technological advances, including significant progress in genomics, the role of nerve biopsy has receded over recent years. However, making a specific and, in some cases, tissue-based diagnosis is essential across a wide array of potentially treatable acquired peripheral neuropathies. When laboratory investigations do not suggest a definitive diagnosis, nerve biopsy remains the final step to ascertain the etiology of the disease. The present review highlights the utility of nerve biopsy in confirming a diagnosis, while further illustrating the importance of a tissue-based diagnosis in relation to treatment strategies, particularly when linked to long-term immunosuppressive therapies.
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Affiliation(s)
- Claudia Sommer
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Antonia S Carroll
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia.,Westmead Clinical School, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Neurology and Neurophysiology, St Vincent's Hospital, The University of NSW, Sydney, New South Wales, Australia
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nora Ort
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Gen Sobue
- Brain and Mind Research Center, Nagoya University, Nagoya, Japan.,Aichi Medical University, Nagakute, Japan
| | - Steve Vucic
- Westmead Clinical School, The University of Sydney, Camperdown, New South Wales, Australia
| | - Judith M Spies
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Neurology, Royal Prince Alfred Hospital, The University of Sydney, Camperdown, New South Wales, Australia
| | - Kathrin Doppler
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Matthew C Kiernan
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Neurology, Royal Prince Alfred Hospital, The University of Sydney, Camperdown, New South Wales, Australia
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29
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Hannaford A, Vucic S, Kiernan MC, Simon NG. Review Article "Spotlight on Ultrasonography in the Diagnosis of Peripheral Nerve Disease: The Evidence to Date". Int J Gen Med 2021; 14:4579-4604. [PMID: 34429642 PMCID: PMC8378935 DOI: 10.2147/ijgm.s295851] [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: 06/22/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Neuromuscular ultrasound is rapidly becoming incorporated into clinical practice as a standard tool in the assessment of peripheral nerve diseases. Ultrasound complements clinical phenotyping and electrodiagnostic evaluation, providing critical structural anatomical information to enhance diagnosis and identify structural pathology. This review article examines the evidence supporting neuromuscular ultrasound in the diagnosis of compressive mononeuropathies, traumatic nerve injury, generalised peripheral neuropathy and motor neuron disease. Extending the sonographic evaluation of nerves beyond simple morphological measurements has the potential to improve diagnostics in peripheral neuropathy, as well as advancing the understanding of pathological mechanisms, which in turn will promote precise therapies and improve therapeutic outcomes.
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Affiliation(s)
- Andrew Hannaford
- Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Steve Vucic
- Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, University of Sydney, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Neil G Simon
- Northern Beaches Clinical School, Macquarie University, Sydney, Australia
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30
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Tsunogae M, Fujiwara S, Shiomi Y, Kikawa Y, Kohara N, Kawamoto M. Eribulin Mesylate-related Multifocal Demyelinating Neuropathy with Myokymia in a Breast Cancer Patient. Intern Med 2021; 60:2687-2691. [PMID: 33678744 PMCID: PMC8429294 DOI: 10.2169/internalmedicine.6780-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report a 48-year-old woman receiving eribulin mesylate for breast cancer who presented with gait disorder, distal limb paresthesia, and weakness progressing monthly. A nerve conduction study indicated demyelination with multifocal conduction block. Considering the immune-mediated pathology of her condition, she was administered intravenous immunoglobulin. Her neurological symptoms improved promptly after intravenous immunoglobulin therapy and eribulin withdrawal. Furthermore, the limb myokymia seen at the time of admission disappeared. Her symptoms continued to improve without additional treatment. We conclude that eribulin was a rare cause of demyelinating neuropathy with multifocal conduction block derived from immune-mediated pathology.
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Affiliation(s)
- Marie Tsunogae
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Satoru Fujiwara
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Yuma Shiomi
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Yuichiro Kikawa
- Department of Breast Surgery, Kobe City Medical Center General Hospital, Japan
| | - Nobuo Kohara
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Michi Kawamoto
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
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Abstract
Paraproteinaemic neuropathies comprise a heterogeneous group of neuro-haematological conditions with some distinct neurological, haematological and systemic phenotypes. The spectrum of disease varies from mild to severe, indolent to rapidly progressive and from small fibre sensory involvement to dramatic sensorimotor deficits. The haematological association may be overlooked, resulting in delayed treatment, disability, impaired quality of life and increased mortality. However, the presence of an irrelevant benign paraprotein can sometimes lead to inappropriate treatment. In this review, we outline our practical approach to paraproteinaemic disorders, discuss the utility and limitations of diagnostic tests and the distinctive clinical phenotypes and touch on the complex multidisciplinary management approaches.
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Affiliation(s)
- Antonia S Carroll
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia.,National Hospital for Neurology and Neurosurgery, London, UK
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32
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Kido K, Wada S, Oka Y, Terada Y, Inoue M, Hamano T. Multifocal motor neuropathy and visual pathway impairment: A case report. Clin Neurophysiol Pract 2021; 6:191-193. [PMID: 34307969 PMCID: PMC8258779 DOI: 10.1016/j.cnp.2021.05.003] [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: 02/03/2021] [Revised: 04/25/2021] [Accepted: 05/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background Multifocal motor neuropathy (MMN) occasionally presents with cranial nerve involvement. However, no MMN cases with visual pathway impairment demonstrated by visual evoked potential (VEP) have been reported. Case report A 36-year-old man was admitted to our hospital with progressive muscular weakness. On admission, neurological findings revealed bilateral muscle weakness and atrophy of the distal upper limbs. The blood tests were positive for GM-1 ganglioside antibodies. Nerve conduction studies revealed bilateral conduction block in the median nerve. He was diagnosed with MMN. Intravenous immunoglobulin treatment improved muscle weakness and blurred vision, which was not a complaint when he was first seen. Moreover, VEP showed a post-treatment shortening of P100 latency. These treatment effects were consistently observed for 3.5 years. Significance Our findings suggested that MMN could affect the visual pathway through autoimmune mechanisms.
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Affiliation(s)
- Keisuke Kido
- Center for Sleep-related Disorders, Kansai Electric Power Hospital, Osaka, Japan.,Division of Sleep Medicine, Kansai Electric Power Medical Research Institute, Osaka, Japan
| | - Shinichi Wada
- Department of Neurology, Kansai Electric Power Hospital, Osaka, Japan
| | - Yuwa Oka
- Division of Clinical Neurology, Kansai Electric Power Medical Research Institute, Osaka, Japan.,Department of Neurology, Kitano Hospital, Osaka, Japan
| | - Yuta Terada
- Department of Neurology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Manabu Inoue
- Department of Neurology, Osaka City General Hospital, Osaka, Japan
| | - Toshiaki Hamano
- Department of Neurology, Kansai Electric Power Hospital, Osaka, Japan.,Division of Clinical Neurology, Kansai Electric Power Medical Research Institute, Osaka, Japan
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Abstract
This edition of What is in the Literature focuses on chronic immune neuropathies as they represent treatable conditions. There are formal criteria to solidify the diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), but patients are encountered who have clinical and electrodiagnostic features of CIDP but do not fulfill diagnostic criteria. These patients are addressed in recent publications. CIDP (and variants) and other forms of immune-mediated neuropathies (multifocal motor neuropathy) are responsive early on to treatment, but long-term factors are less well described, and a number of publications focus on extended consequences. Acute immune neuropathies have been described in the setting of viral illness, and recent publications look at the question as to whether they are associated with the COVID-19 pandemic. Finally, idiopathic sensory neuropathies are the most common polyneuropathy, and consensus efforts to codify features into subtypes can be used clinically for a more precise diagnosis.
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Affiliation(s)
- Mark B Bromberg
- Department of Neurology, University of Utah, Salt Lake City, UT
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34
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Safety and efficacy of CAR T cells in a patient with lymphoma and a coexisting autoimmune neuropathy. Blood Adv 2021; 4:6019-6022. [PMID: 33284942 DOI: 10.1182/bloodadvances.2020003176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022] Open
Abstract
Key Points
CAR T-cell therapy was safe and effective in a DLBCL patient with coexisting autoimmune neuropathy. CD19 CAR T-cell therapy may control refractory autoantibodies and monoclonal gammopathies.
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35
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Kiernan MC. Neurology and clinical neurophysiology: an artificial divide. Pract Neurol 2021; 21:practneurol-2021-002946. [PMID: 33910987 DOI: 10.1136/practneurol-2021-002946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Matthew C Kiernan
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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36
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High-resolution mapping identifies HLA class II associations with multifocal motor neuropathy. Neurobiol Aging 2021; 101:79-84. [PMID: 33582569 DOI: 10.1016/j.neurobiolaging.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/10/2020] [Accepted: 01/16/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To gain further insight in the immunopathology underlying multifocal motor neuropathy (MMN) by exploring the association between MMN and the human leukocyte antigen (HLA) class II DRB1, DQB1, and DQA loci in depth and by correlating associated haplotypes to detailed clinical and anti-ganglioside antibody data. METHODS We performed high-resolution HLA-class II typing for the DRB1, DQB1, and DQA1 loci in 126 well-characterized MMN patients and assessed disease associations with haplotypes. We used a cohort of 1305 random individuals as a reference for haplotype distribution in the Dutch population. RESULTS The DRB1*15:01-DQB1*06:02 haplotype (OR 1.6 [95% CI 1.1-2.2], p < 0.05) and the DRB1*12:01-DQB1*03:01 haplotype (OR 2.7 [95% CI 1.2-5.5], p < 0.05) were more frequent in patients with MMN than in controls. These haplotypes were not associated with disease course, response to treatment or anti-ganglioside antibodies. CONCLUSIONS MMN is associated with the DRB1*15:01-DQB1*06:02 and DRB1*12:01-DQB1*03:01 haplotypes. These HLA molecules or gene variants in their immediate vicinity may promote the specific inflammatory processes underlying MMN.
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37
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Tsuji Y, Noto YI, Kitaoji T, Kojima Y, Mizuno T. Difference in distribution of fasciculations between multifocal motor neuropathy and amyotrophic lateral sclerosis. Clin Neurophysiol 2020; 131:2804-2808. [PMID: 33137570 DOI: 10.1016/j.clinph.2020.08.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/28/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine differences in fasciculation distribution between patients with multifocal motor neuropathy (MMN) and amyotrophic lateral sclerosis (ALS) based on muscle ultrasound. METHODS Forty-one muscles (tongue muscle and 40 muscles of the trunk and limbs on both sides) in 5 MMN patients and 21 muscles (tongue muscle and 20 muscles on the onset side) in 21 ALS patients were subjected to muscle ultrasound individually for 60 seconds to detect the presence of fasciculations. RESULTS Fasciculation detection rates on the onset side were significantly higher in ALS (42.4 ± 18.3%, mean ± SD) than in MMN (21.9 ± 8.8%) patients (p < 0.05). In MMN patients, no fasciculation was detected in the tongue or truncal muscles. There was no difference in the fasciculation detection rate between the onset and non-onset sides or between upper and lower limbs in MMN patients. CONCLUSIONS In MMN patients, fasciculations were detected extensively in the limbs. However, the detection rate in patients with MMN was lower than in those with ALS. SIGNIFICANCE Demonstration of the absence of fasciculations in the tongue and truncal muscles in MMN patients by extensive muscle ultrasound examination may help distinguish MMN from ALS.
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Affiliation(s)
- Yukiko Tsuji
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yu-Ichi Noto
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Takamasa Kitaoji
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuta Kojima
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshiki Mizuno
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Topakian R, Müller P, Ciovica-Oel IC, Trenkler J. In the borderland of multifocal motor neuropathy and chronic inflammatory demyelinating polyradiculopathy. Neurol Sci 2020; 42:1131-1134. [PMID: 33074453 DOI: 10.1007/s10072-020-04804-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
Chronic inflammatory demyelinating polyradiculopathy (CIDP) and multifocal motor neuropathy (MMN) are seen as distinct entities with marked differences in pathophysiology and clinical, laboratory, and imaging features. We report a patient with an immune-mediated neuropathy in the borderland of CIDP and MMN, whose magnetic resonance imaging and cerebrospinal fluid (CSF) features strongly resembled CIDP, while the clinical course and treatment response suggested the diagnosis of MMN without conduction blocks. There is strong evidence that MMN is not a variant of CIDP and that these conditions can be separated pathologically. Our case report widens the spectrum of MMN presentations, indicating the existence of a clinical overlap syndrome of MMN and CIDP, and emphasizing the need for more precise criteria regarding CSF and nerve root imaging abnormalities in the differentiation of chronic immune-mediated neuropathies.
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Affiliation(s)
- Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Grieskirchner Str. 42, 4600, Wels, Austria.
| | - Petra Müller
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Grieskirchner Str. 42, 4600, Wels, Austria
| | | | - Johannes Trenkler
- Institute of Neuroradiology, Kepler University Hospital, Linz, Austria
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Gwathmey K. Chronic Inflammatory Demyelinating Polyradiculoneuropathy and Its Variants. Continuum (Minneap Minn) 2020; 26:1205-1223. [PMID: 33002999 DOI: 10.1212/con.0000000000000907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and its variants comprise a group of immune-mediated neuropathies with distinctive clinical presentations and electrodiagnostic features. Prompt recognition of these treatable disorders is mandatory as delays result in significant disability and morbidity. This article highlights the clinical presentation, pathophysiology, diagnostic evaluation, and treatment approach of these polyneuropathies. RECENT FINDINGS The spectrum of CIDP is expanding with the recent characterization of neuropathies associated with nodal and paranodal antibodies. These neuropathies are distinguished by their unique presentations and are often refractory to IV immunoglobulin (IVIg) therapy. Subcutaneous immunoglobulins have recently been approved as a treatment option for CIDP and join corticosteroids, IVIg, and plasma exchange as first-line treatment. SUMMARY CIDP is characterized by progressive symmetric proximal and distal weakness, large fiber sensory loss, and areflexia, with clinical nadir reached more than 8 weeks after symptom onset. Autoimmune demyelinating neuropathies fall on a continuum, with differences in the type of nerve fibers affected and pattern of deficits. Distinguishing between typical CIDP and its variants allows for selection of the most appropriate treatment.
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40
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Tuchman SA, Zonder JA. The Spectrum of Monoclonal Immunoglobulin-Associated Diseases. Hematol Oncol Clin North Am 2020; 34:997-1008. [PMID: 33099435 DOI: 10.1016/j.hoc.2020.07.002] [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: 11/16/2022]
Abstract
The spectrum of immunoglobulin paraprotein-associated diseases requiring therapy extends beyond multiple myeloma and AL amyloidosis. Awareness of these is essential in ensuring timely accurate diagnosis and appropriate treatment. As most paraprotein-associated diseases are fairly uncommon, therapeutic decisions must often be made in the absence of data from randomized controlled trials. Treatment is generally directed at the underlying clonal cell population. This review focuses on the spectrum of the less common paraprotein-associated disorders. In most instances, the monoclonal immunoglobulin plays a direct role in the pathophysiology of the disease course; in a select few, the paraprotein may be a disease marker.
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Affiliation(s)
- Sascha A Tuchman
- Division of Hematology, University of North Carolina - Chapel Hill, Comprehensive Cancer Center, 170 Manning Dr., CB#7305, Chapel Hill, NC 27599, USA
| | - Jeffrey A Zonder
- Barbara Ann Karmanos Cancer Institute/Wayne State University School of Medicine, Myeloma and Amyloidosis Team, Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA.
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41
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Sahi N, Ghasemi M, Rajabally YA. Autoantibodies in the diagnostic work-up of neuropathy: clinically useful or purely academic? Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32730155 DOI: 10.12968/hmed.2020.0085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The search for autoantibodies in patients with acute and chronic neuropathies has become widespread in neurological practice. These tests are more routinely available and therefore are more commonly requested in larger hospitals with neuroscience centres, although they are now also regularly requested from district general hospital settings, including by non-neurologists. However, the clinical value of these frequently expensive tests is often unclear and their impact on management not always obviously beneficial. This article reviews the main immunological tests used to search for specific autoantibodies in the setting of neuropathy and discusses their potential diagnostic importance, together with the eventual therapeutic implications of results obtained.
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Affiliation(s)
- Nitin Sahi
- Regional Neuromuscular Service, Queen Elizabeth Hospital, University Hospitals Birmingham, UK
| | - Majid Ghasemi
- Regional Neuromuscular Service, Queen Elizabeth Hospital, University Hospitals Birmingham, UK
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Queen Elizabeth Hospital, University Hospitals Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
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Gastaldi M, Zardini E, Scaranzin S, Uccelli A, Andreetta F, Baggi F, Franciotta D. Autoantibody Diagnostics in Neuroimmunology: Experience From the 2018 Italian Neuroimmunology Association External Quality Assessment Program. Front Neurol 2020; 10:1385. [PMID: 32010046 PMCID: PMC6971200 DOI: 10.3389/fneur.2019.01385] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/16/2019] [Indexed: 12/31/2022] Open
Abstract
Background: Neuroimmunology has impressively expanded in the past decade. Novel assays, especially cell-based assays (CBAs) can detect conformational antibodies (Abs) recognizing antigens in their native conformation. Generally, the availability of in-house and of commercial tests has improved the diagnostics, but introduced demanding laboratory tasks. Hence, standardization and quality controls represent a key step to promote accuracy. We report on the results of the 2018 external quality assessment program (EQAP) organized by the Italian Neuroimmunology Association. Methods: EQAP regarded 10 schemes, including oligoclonal bands (OCBs), intracellular-neuronal (ICN)-Abs, neuronal-surface (NS)-Abs, aquaporin-4 (AQP4)-Abs, myelin oligodendrocyte glycoprotein (MOG)-Abs, myelin-associated glycoprotein (MAG)-Abs, ganglioside-Abs, acetylcholine-receptor (AChR)-Abs, and muscle-specific-kinase (MuSK)-Abs, and 34 laboratories. Assays were classified as tissue-based assays (TBAs), solid-phase assays (SPAs), liquid-phase assays (LPAs), and CBAs. Thirty-three samples were provided. Results: Three-quarter of the tests were commercial. Median accuracy for the laboratories was 75% (range 50–100). In 8/10 schemes, at least one sample provided discrepant results. Inter-laboratory “substantial agreement” was found in 6/10 schemes (AChR, MuSK, MAG, AQP4, MOG, and NS-Abs), whereas the worst agreements regarded OCBs and ganglioside-Abs. Both commercial and in-house assays performed better in experienced laboratories. Conclusions: Assays could be divided in (a) robust commercial tests with substantial inter-laboratory agreement (MAG-Abs; AChR- and MuSK-Abs); commercial/“in-house” tests with (b) partial inter-laboratory agreement (AQP4-Abs, MOG-Abs, NS-Abs, ICN-Abs), and (c) with large inter-laboratory disagreement (OCBs, ganglioside-Abs). This real-life snapshot of the neuroimmunology test performances highlights shortcomings attributable to technician-dependent performances, assay structural limitations, and errors in test interpretations.
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Affiliation(s)
- Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Elisabetta Zardini
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Science, University of Pavia, Pavia, Italy
| | - Silvia Scaranzin
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
| | - Antonio Uccelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | - Francesca Andreetta
- UO Neurology IV, IRCCS Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Fulvio Baggi
- UO Neurology IV, IRCCS Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
| | - Diego Franciotta
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, Pavia, Italy
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A Curious Case of Acute Onset Bilateral Hand Weakness in a Youth Hockey Player: A Case Report. Am J Phys Med Rehabil 2019; 99:656-659. [PMID: 31688010 DOI: 10.1097/phm.0000000000001343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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