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Hannaford A, Paling E, Silsby M, Vincenten S, van Alfen N, Simon NG. Electrodiagnostic studies and new diagnostic modalities for evaluation of peripheral nerve disorders. Muscle Nerve 2024; 69:653-669. [PMID: 38433118 DOI: 10.1002/mus.28068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 03/05/2024]
Abstract
Electrodiagnostic studies (EDx) are frequently performed in the diagnostic evaluation of peripheral nerve disorders. There is increasing interest in the use of newer, alternative diagnostic modalities, in particular imaging, either to complement or replace established EDx protocols. However, the evidence to support this approach has not been expansively reviewed. In this paper, diagnostic performance data from studies of EDx and other diagnostic modalities in common peripheral nerve disorders have been analyzed and described, with a focus on radiculopathy, plexopathy, compressive neuropathies, and the important neuropathy subtypes of Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), vasculitic neuropathy and diabetic neuropathy. Overall EDx retains its place as a primary diagnostic modality in the evaluated peripheral nerve disorders. Magnetic resonance imaging and ultrasound have developed important complementary diagnostic roles in compressive and traumatic neuropathies and atypical CIDP, but their value is more limited in other neuropathy subtypes. Identification of hourglass constriction in nerves of patients with neuralgic amyotrophy may have therapeutic implications. Investigation of radiculopathy is confounded by poor correlation between clinical features and imaging findings and the lack of a diagnostic gold standard. There is a need to enhance the literature on the utility of these newer diagnostic modalities.
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Affiliation(s)
- Andrew Hannaford
- Department of Neurology, Concord Hospital, Sydney, New South Wales, Australia
- Brain and Nerve Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Elijah Paling
- School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Matthew Silsby
- Department of Neurology, Concord Hospital, Sydney, New South Wales, Australia
- Brain and Nerve Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sanne Vincenten
- Department of Neurology and Clinical Neurophysiology, Radboud University Medical Center, Donders Center for Neuroscience, Nijmegen, the Netherlands
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiology, Radboud University Medical Center, Donders Center for Neuroscience, Nijmegen, the Netherlands
| | - Neil G Simon
- Northern Beaches Clinical School, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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2
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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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3
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Collins MP, Hadden RDM, Shahnoor N. Primary perineuritis, a rare but treatable neuropathy: Review of perineurial anatomy, clinicopathological features, and differential diagnosis. Muscle Nerve 2023; 68:696-713. [PMID: 37602939 DOI: 10.1002/mus.27949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/10/2023] [Accepted: 07/16/2023] [Indexed: 08/22/2023]
Abstract
The perineurium surrounds each fascicle in peripheral nerves, forming part of the blood-nerve barrier. We describe its normal anatomy and function. "Perineuritis" refers to both a nonspecific histopathological finding and more specific clinicopathological entity, primary perineuritis (PP). Patients with PP are often assumed to have nonsystemic vasculitic neuropathy until nerve biopsy is performed. We systematically reviewed the literature on PP and developed a differential diagnosis for histopathologically defined perineuritis. We searched PubMed, Embase, Scopus, and Web of Science for "perineuritis." We identified 20 cases (11 M/9F) of PP: progressive, unexplained neuropathy with biopsy showing perineuritis without vasculitis or other known predisposing condition. Patients ranged in age from 18 to 75 (mean 53.7) y and had symptoms 2-24 (median 4.5) mo before diagnosis. Neuropathy was usually sensory-motor (15/20), painful (18/19), multifocal (16/20), and distal-predominant (16/17) with legs more affected than arms. Truncal numbness occurred in 6/17; 10/18 had elevated cerebrospinal fluid (CSF) protein. Electromyography (EMG) and nerve conduction studies (NCS) demonstrated primarily axonal changes. Nerve biopsies showed T-cell-predominant inflammation, widening, and fibrosis of perineurium; infiltrates in epineurium in 10/20 and endoneurium in 7/20; and non-uniform axonal degeneration. Six had epithelioid cells. 19/20 received corticosteroids, 8 with additional immunomodulators; 18/19 improved. Two patients did not respond to intravenous immunoglobulin (IVIg). At final follow-up, 13/16 patients had mild and 2/16 moderate disability; 1/16 died. Secondary causes of perineuritis include leprosy, vasculitis, neurosarcoidosis, neuroborreliosis, neurolymphomatosis, toxic oil syndrome, eosinophilia-myalgia syndrome, and rarer conditions. PP appears to be an immune-mediated, corticosteroid-responsive disorder. It mimics nonsystemic vasculitic neuropathy. Cases with epithelioid cells might represent peripheral nervous system (PNS)-restricted forms of sarcoidosis.
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Affiliation(s)
- Michael P Collins
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Nazima Shahnoor
- Neuromuscular Pathology Laboratory, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Schneider C, Wassermann MK, Svačina MKR, Wunderlich G, Fink GR, Lehmann HC. Subclinical motor involvement in nonsystemic vasculitic neuropathy determined by the motor unit number estimation method MScanFit. Muscle Nerve 2023; 67:474-480. [PMID: 36905193 DOI: 10.1002/mus.27813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/12/2023]
Abstract
INTRODUCTION/AIMS Nonsystemic vasculitic neuropathy (NSVN) is characterized by a predominant lower limb involvement in many patients. Motor unit changes in upper extremity muscles have not been investigated in this subgroup but may be of interest for improving our understanding of the multifocal nature of the disease and counseling of patients about potential future symptoms. In this study we aimed to better understand subclinical motor involvement in the upper extremity muscles of patients with lower limb-predominant NSVN using the new motor unit number estimation (MUNE) method MScanFit. METHODS In this single-center, cross-sectional study, 14 patients with biopsy-proven NSVN, with no clinical signs of upper extremity motor involvement, were investigated and compared with 14 age-matched healthy controls. All participants were assessed clinically and by the MUNE method MScanFit to the abductor pollicis brevis muscle. RESULTS The number of motor units and peak CMAP amplitudes were significantly reduced in patients with NSVN (P = .003 and P = .004, respectively). Absolute median motor unit amplitudes and CMAP discontinuities were not significantly different (P = .246 and P = .1, respectively). CMAP discontinuities were not significantly correlated with motor unit loss (P = .15, rho = 0.4). The number of motor units did not correlate with clinical scores (P = .77, rho = 0.082). DISCUSSION Both MUNE and CMAP amplitudes showed motor involvement in upper extremity muscles in lower limb-predominant NSVN. Overall, there was no evidence of significant reinnervation. Investigations of the abductor pollicis brevis muscle did not show a correlation with overall functional disability of the patients.
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Affiliation(s)
- Christian Schneider
- Department of Neurology, Medical Faculty and University Hospital of Cologne, Cologne, Germany
| | - Meike K Wassermann
- Department of Neurology, Medical Faculty and University Hospital of Cologne, Cologne, Germany
| | - Martin K R Svačina
- Department of Neurology, Medical Faculty and University Hospital of Cologne, Cologne, Germany
| | - Gilbert Wunderlich
- Department of Neurology, Medical Faculty and University Hospital of Cologne, Cologne, Germany
- Center for Rare Diseases, Medical Faculty and University Hospital of Cologne, Cologne, Germany
| | - Gereon R Fink
- Department of Neurology, Medical Faculty and University Hospital of Cologne, Cologne, Germany
- Institute of Neuroscience and Medicine, Research Center Jülich, Jülich, Germany
| | - Helmar C Lehmann
- Department of Neurology, Medical Faculty and University Hospital of Cologne, Cologne, Germany
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5
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[Peripheral neuropathies during systemic diseases: Part II (vasculitis)]. Rev Med Interne 2023; 44:174-180. [PMID: 36925342 DOI: 10.1016/j.revmed.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/08/2023] [Indexed: 03/15/2023]
Abstract
Primary systemic vasculitides, mainly of the small and medium-sized vessels, are frequently associated with peripheral neuropathies. When the disease is already known, the appearance of a neuropathy should suggest a specific injury, especially when associated with other systemic manifestations. Conversely, when neuropathy is inaugural, close collaboration between neurologists and internists is necessary to reach a diagnosis. A standardized electro-clinical investigation specifying the topography, the evolution and the mechanism of the nerve damage enables the positive diagnosis of the neuropathy. Several elements orient the etiological diagnosis and allow to eliminate the main differential diagnosis: non systemic vasculitic neuropathy. The existence of associated systemic manifestations (glomerular or vascular nephropathy, interstitial lung disease, intra-alveolar hemorrhage, ENT involvement…), biological markers (ANCA, cryoglobulinemia, rheumatoid factor), and invasive examinations allowing histological analysis (neuromuscular biopsy) are all useful tools for.
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Mansueto G, Lanza G, Falleti J, Orabona P, Alaouieh D, Hong E, Girolami S, Montella M, Fisicaro F, Galdieri A, Singh P, Di Napoli M. Central and Peripheral Nervous System Complications of Vasculitis Syndromes from Pathology to Bedside: Part 2-Peripheral Nervous System. Curr Neurol Neurosci Rep 2023; 23:83-107. [PMID: 36820992 PMCID: PMC9947450 DOI: 10.1007/s11910-023-01249-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Peripheral nervous system vasculitides (PNSV) are a heterogeneous group of disorders with a clinical subset that may differ in prognosis and therapy. We provide a comprehensive update on the clinical assessment, diagnosis, complications, treatment, and follow-up of PNSV. RECENT FINDINGS Progress in neuroimaging, molecular testing, and peripheral nerve biopsy has improved clinical assessment and decision-making of PNSV, also providing novel insights on how to prevent misdiagnosis and increase diagnostic certainty. Advances in imaging techniques, allowing to clearly display the vessel walls, have also enhanced the possibility to differentiate inflammatory from non-inflammatory vascular lesions, while recent histopathology data have identified the main morphological criteria for more accurate diagnosis and differential diagnoses. Overall, the identification of peculiar morphological findings tends to improve diagnostic accuracy by defining a clearer boundary between systemic and non-systemic neuropathies. Therefore, the definition of epineurium vessel wall damage, type of vascular lesion, characterization of lymphocyte populations, antibodies, and inflammatory factors, as well as the identification of direct nerve damage or degeneration, are the common goals for pathologists and clinicians, who will both benefit for data integration and findings translation. Nevertheless, to date, treatment is still largely empiric and, in some cases, unsatisfactory, thus often precluding precise prognostic prediction. In this context, new diagnostic techniques and multidisciplinary management will be essential in the proper diagnosis and prompt management of PNSV, as highlighted in the present review. Thirty to fifty percent of all patients with vasculitis have signs of polyneuropathy. Neuropathies associated with systemic vasculitis are best managed according to the guidelines of the underlying disease because appropriate workup and initiation of treatment can reduce morbidity. Steroids, or in severe or progressive cases, cyclophosphamide pulse therapy is the standard therapy in non-systemic vasculitic neuropathies. Some patients need long-term immunosuppression. The use of novel technologies for high-throughput genotyping will permit to determine the genetic influence of related phenotypes in patients with PNSV.
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Affiliation(s)
- Gelsomina Mansueto
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Piazza L. Miraglia 2, 80138, Naples, Italy.,Clinical Department of Laboratory Services and Public Health-Legal Medicine Unit, University of Campania "Luigi Vanvitelli", Via Luciano Armanni 5, 80138, Naples, Italy.,Pathology-Unit of Federico II University, Via S. Pansini 3, 80131, Naples, Italy
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia 78, 95123, Catania, Italy.,Clinical Neurophysiology Research Unit, Oasi Research Institute-IRCCS, Via Conte Ruggero 73, 94018, Troina, Italy
| | - Jessica Falleti
- Pathology Unit, Sant'Anna E San Sebastiano Hospital, 81100, Caserta, Italy
| | - Pasquale Orabona
- Pathology Unit, Sant'Anna E San Sebastiano Hospital, 81100, Caserta, Italy
| | | | - Emily Hong
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Sara Girolami
- Neurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039, Sulmona, L'Aquila, Italy
| | - Marco Montella
- Mental and Physical Health and Preventive Medicine Department, University of Campania "Luigi Vanvitelli", Via Luciano Armanni 5, 80138, Naples, Italy
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123, Catania, Italy
| | - Anna Galdieri
- AOU "Luigi Vanvitelli", Via Santa Maria Di Costantinopoli 104, 80138, Naples, Italy
| | - Puneetpal Singh
- Department of Human Genetics, Punjabi University, Patiala, 147002, Punjab, India
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Viale Mazzini 100, 67039, Sulmona, L'Aquila, Italy.
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Aladawi M, Shelly S, Dyck PJB, Koster M, Engelstad J, Piccione EA, Naddaf E. Nitrofurantoin and Minocycline-Associated Vasculitic Neuropathy: Case Reports and Literature Review. J Clin Neuromuscul Dis 2022; 24:85-94. [PMID: 36409339 DOI: 10.1097/cnd.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Vasculitic neuropathies usually present acutely to subacutely, with an asymmetric pattern, involving multiple peripheral nerve territories. Drug-induced vasculitis is an often overlooked etiology of vasculitic neuropathy. METHODS We present the first reported case of nitrofurantoin-associated and an illustrative case of minocycline-associated vasculitic neuropathy, with a review of the literature. RESULTS The first patient is a 60-year-old woman who developed axonal sensorimotor peripheral neuropathy after nitrofurantoin use, with a superficial radial nerve biopsy confirming vasculitis. The second patient is a 23-year-old woman, with a history of acne vulgaris treated with minocycline, who presented with a subacute right common peroneal mononeuropathy followed by a left deep peroneal mononeuropathy, with elevated antinuclear, perinuclear-antineutrophil cytoplasmic, and myleoperoxidase antibodies, and MPO titers, and a sural nerve biopsy showing large arteriole vasculitis. Finally, we provide a comprehensive review of previously published cases. CONCLUSIONS Medications should be considered as a trigger for medication-induced vasculitic neuropathy. Accurate diagnosis would ensure timely treatment.
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Affiliation(s)
- Mohammad Aladawi
- Departement of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | | | | | - Matthew Koster
- Deparmtent of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN; and
| | - JaNean Engelstad
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ezequiel A Piccione
- Departement of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE
| | - Elie Naddaf
- Department of Neurology, Mayo Clinic, Rochester, MN
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Fukami Y, Koike H, Katsuno M. Current perspectives on the diagnosis, assessment, and management of vasculitic neuropathy. Expert Rev Neurother 2022; 22:941-952. [PMID: 36609209 DOI: 10.1080/14737175.2022.2166831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Vasculitic neuropathy can present associated with both primary and secondary systemic vasculitis as a result from underlying diseases such as rheumatic diseases and infections, Moreover, confined vasculitis in the peripheral nervous system may be present. Thus, the diagnosis and management of vasculitic neuropathy require multidisciplinary approaches. AREAS COVERED Current views as well as relevant clinical research on the diagnosis, assessment, and management of vasculitic neuropathy are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for reports published between July 2017 and July 2022. EXPERT OPINION For the treatment of vasculitic neuropathy, determining the causative primary disease is important and often requires diagnosis by tissue biopsy. Due to the scarce research on the treatment of vasculitic neuropathy, treatment is empirically based on findings from studies of systemic vasculitides involving other organs, particularly antineutrophil cytoplasmic antibody-associated vasculitis. In addition to conventional glucocorticoids and immunosuppressive agents, complement-targeted therapy, anti-B-cell therapy, and disease-specific molecular targeted therapies have recently gained relevance. Future research is needed to develop new patient-specific therapeutic options.
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Affiliation(s)
- Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Clinical Research Education, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Emerging Role of Neuron-Glia in Neurological Disorders: At a Glance. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:3201644. [PMID: 36046684 PMCID: PMC9423989 DOI: 10.1155/2022/3201644] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/05/2022] [Indexed: 11/18/2022]
Abstract
Based on the diverse physiological influence, the impact of glial cells has become much more evident on neurological illnesses, resulting in the origins of many diseases appearing to be more convoluted than previously happened. Since neurological disorders are often random and unknown, hence the construction of animal models is difficult to build, representing a small fraction of people with a gene mutation. As a result, an immediate necessity is grown to work within in vitro techniques for examining these illnesses. As the scientific community recognizes cell-autonomous contributions to a variety of central nervous system illnesses, therapeutic techniques involving stem cells for treating neurological diseases are gaining traction. The use of stem cells derived from a variety of sources is increasingly being used to replace both neuronal and glial tissue. The brain's energy demands necessitate the reliance of neurons on glial cells in order for it to function properly. Furthermore, glial cells have diverse functions in terms of regulating their own metabolic activities, as well as collaborating with neurons via secreted signaling or guidance molecules, forming a complex network of neuron-glial connections in health and sickness. Emerging data reveals that metabolic changes in glial cells can cause morphological and functional changes in conjunction with neuronal dysfunction under disease situations, highlighting the importance of neuron-glia interactions in the pathophysiology of neurological illnesses. In this context, it is required to improve our understanding of disease mechanisms and create potential novel therapeutics. According to research, synaptic malfunction is one of the features of various mental diseases, and glial cells are acting as key ingredients not only in synapse formation, growth, and plasticity but also in neuroinflammation and synaptic homeostasis which creates critical physiological capacity in the focused sensory system. The goal of this review article is to elaborate state-of-the-art information on a few glial cell types situated in the central nervous system (CNS) and highlight their role in the onset and progression of neurological disorders.
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Schneider C, Wassermann MK, Fink GR, Lehmann HC. Single-center experience of induction therapy in non-systemic vasculitic neuropathy. Neurol Res Pract 2022; 4:32. [PMID: 35965348 PMCID: PMC9377119 DOI: 10.1186/s42466-022-00198-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background No controlled studies for non-systemic vasculitic neuropathy treatment exist (NSVN). We compared the treatment response to induction therapy commonly used in clinical practice in NSVN. Methods In this retrospective single-center study, 43 patients with biopsy-proven NSVN were analyzed. Patients were subdivided into groups depending on their initial treatment. Relapse rates, changes of motor and sensory symptoms, adverse events, predictors of relapses, and second-line treatment were compared. Results Initial treatment regimens were corticosteroid monotherapy, cyclophosphamide monotherapy, pulsed corticosteroid therapy, and combination therapy. Discontinuation due to adverse events occurred in 6 of 43 patients. Clinical data did not differ between treatment groups. Within 12 months, 24.3% of patients relapsed. The median time to relapse was 4 (1.5, 6) months. No relapse occurred in the combination therapy group. However, there was no statistically significant difference in relapse-free survival between treatment groups (p = 0.58). Neither clinical data nor biopsy analysis predicted relapses sufficiently. As a second-line treatment, cyclophosphamide as mono- or combination therapy was used (7 of 9 patients) most frequently. One patient was treated with methotrexate, and one with IVIG. Conclusions Induction therapy used in clinical practice is effective and mainly well-tolerated in NSVN. Our data do not support an overall advantage of cyclophosphamide over corticosteroid monotherapy. Controlled trials comparing the effectiveness of induction and maintenance therapy in NSVN are warranted.
Supplementary Information The online version contains supplementary material available at 10.1186/s42466-022-00198-5.
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Etgen T, Winklmaier M. [First clinical manifestation of chronic hepatitis C in painless progressive atrophic monoparesis of the right leg]. Dtsch Med Wochenschr 2022; 147:613-616. [PMID: 35545070 DOI: 10.1055/a-1799-1850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
HISTORY AND CLINICAL FINDINGS A 60-year-old male patient was admitted with a painless reduction in the circumference of the right calf with mild gait disturbance that had been increasing for 6 months. Neurological findings included atrophic monoparesis of the right lower leg with preserved muscle reflexes without sensory disturbances. INVESTIGATIONS Electrophysiologically and neuroradiologically, only the right triceps surae muscle showed signs of combined acute and chronic damage and marked atrophy with diffuse muscle oedema. With elevated liver enzymes, previously unknown positive hepatitis C serology and high hepatitis C viral load in serum, even pleocytosis with very low viral load was detectable in the CSF. DIAGNOSIS A diagnosis of hepatitis C-associated mononeuropathy of the right sciatic nerve with focal involvement of the right tibial nerve was made. THERAPY AND COURSE After therapy with Sofosbuvir and Velpatasvir, no further progression of the monoparesis occurred during the further course. CONCLUSIONS Chronic hepatitis C may be rarely associated with painless progressive monoparesis. With regard to pathogenesis, the significance of CSF requires further studies.
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Affiliation(s)
- Thorleif Etgen
- Klinik für Neurologie, Klinikum Traunstein.,Klinik und Poliklinik für Psychiatrie und Psychotherapie, Technische Universität München
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12
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Claytor B, Li Y. Opinions on pneumocystis jirovecci prophylaxis in autoimmune neuromuscular disorders. Muscle Nerve 2021; 65:278-283. [PMID: 34952994 DOI: 10.1002/mus.27481] [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: 06/23/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 11/09/2022]
Abstract
Pneumocystis jirovecci (PJ) is ubiquitously present in the environment and capable of causing an interstitial pneumonia in immunocompromised subjects. It has been advocated that routine prophylaxis against PJ be given to patients with autoimmune neuromuscular conditions which require prolonged usage of corticosteroid therapy and/or other immunosuppressive agents. Available data, however, suggest that the risk of PJ infection in patients with autoimmune neuromuscular diseases is extremely low and a widespread usage of prophylactic therapy is likely unnecessary. Comorbidities including intestinal lung disease, prolonged lymphopenia, low CD4 count, parenchymal organ failure, and active cancer status appear to increase risk for PJ infection, and it is our opinion that these risk factors should be considered to determine the risk of PJ infection and the requirement for prophylaxis.
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Affiliation(s)
- Benjamin Claytor
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yuebing Li
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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13
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Martins-Martinho J, Dourado E, Khmelinskii N, Espinosa P, Ponte C. Localized Forms of Vasculitis. Curr Rheumatol Rep 2021; 23:49. [PMID: 34196889 PMCID: PMC8247627 DOI: 10.1007/s11926-021-01012-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 12/26/2022]
Abstract
Purpose of Review To provide an updated review on epidemiology, clinical manifestations, diagnostic assessment, treatment, and prognosis of localized vasculitis, following the 2012 Revised International Chapel Hill Consensus Conference Nomenclature on single-organ vasculitis. Recent Findings Localized, single-organ vasculitides encompass a group of rare conditions in which there is no evidence of concomitant systemic vasculitis. Most data on this topic derives from case reports and small case series. Although some aspects of these diseases, such as clinical manifestations and histologic findings, have already been extensively investigated, there is still a lack of robust data concerning the pathogenesis, epidemiology, and treatment. Summary Localized vasculitides may have a wide range of clinical features depending on the organ affected. The inflammatory process may have a multifocal/diffuse or unifocal distribution. Diagnosis is usually based on histopathology findings and exclusion of systemic vasculitis, which may frequently pose a challenge. Further research on treatment is warranted.
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Affiliation(s)
- Joana Martins-Martinho
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal. .,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
| | - Eduardo Dourado
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Nikita Khmelinskii
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Pablo Espinosa
- Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal
| | - Cristina Ponte
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal.,Dermatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, 1649-035, Lisbon, Portugal
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14
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Cox SZ, Gwathmey KG. Chronic Immune-Mediated Polyneuropathies. Clin Geriatr Med 2021; 37:327-345. [PMID: 33858614 DOI: 10.1016/j.cger.2021.01.006] [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: 10/21/2022]
Abstract
This article discusses the chronic immune-mediated polyneuropathies, a broad category of acquired polyneuropathies that encompasses chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), the most common immune-mediated neuropathy, the CIDP variants, and the vasculitic neuropathies. Polyneuropathies associated with rheumatological diseases and systemic inflammatory diseases, such as sarcoidosis, will also be briefly covered. These patients' history, examination, serum studies, and electrodiagnostic studies, as well as histopathological findings in the case of vasculitis, confirm the diagnosis and differentiate them from the more common length-dependent polyneuropathies. Prompt identification and initiation of treatment is imperative for these chronic immune-mediated polyneuropathies to prevent disability and even death.
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Affiliation(s)
- Stephen Zachary Cox
- Department of Neurology, Virginia Commonwealth University, 1101 East Marshall Street, PO Box 980599, Richmond, VA 23298, USA
| | - Kelly G Gwathmey
- Department of Neurology, Virginia Commonwealth University, 1101 East Marshall Street, PO Box 980599, Richmond, VA 23298, USA.
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Pinto MV, Ng PS, Howe BM, Laughlin RS, Thapa P, Dyck PJ, Dyck PJB. Lumbosacral Radiculoplexus Neuropathy: Neurologic Outcomes and Survival in a Population-Based Study. Neurology 2021; 96:e2098-e2108. [PMID: 33653898 DOI: 10.1212/wnl.0000000000011799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/19/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether patients in the community with lumbosacral radiculoplexus neuropathy (LRPN) have milder neuropathy than referral patients, we characterized the outcomes and survival of population-based compared to referral-based LRPN cohorts. BACKGROUND Previously, we found that the incidence of LRPN is 4.16/100,000/y, a frequency greater than other inflammatory neuropathies. The survival of patients with LRPN is uncharacterized. METHODS Sixty-two episodes in 59 patients with LRPN were identified over 16 years (2000-2015). Clinical findings were compared to previous referral-based LRPN cohorts. Survival data were compared to those of age- and sex-matched controls. RESULTS At LRPN diagnosis, median age was 70 years, median Neuropathy Impairment Score (NIS) 22 points, 92% had pain, 95% had weakness, 23% were wheelchair-bound, and median modified Rankin Scale score (mRS) was 3 (range 1-4). At last follow-up, median NIS improved to 17 points (p < 0.001) with 56% having ≥4 points improvement, 16% were wheelchair-bound, and median mRS was 2. Compared to referral-based LRPN cohorts, community patients with LRPN had less impairment, less bilateral disease (37% vs 92%), and less wheelchair usage (23% vs 49%). LRPN survival was 86% at 5 years and 55% at 10 years. Compared to age- and sex-matched controls, patients with LRPN had 76% increased risk of death (p = 0.016). In multivariate analysis, diabetes, age, stroke, chronic kidney disease, peripheral artery disease, and coronary artery disease were significant mortality risk factors but LRPN was not. CONCLUSION LRPN is a painful, paralytic, asymmetric, monophasic, sometimes bilateral pan-plexopathy that improves over time but leaves patients with impairment. Although having LRPN increases mortality, this increase is probably due to comorbidities (diabetes) rather than LRPN itself.
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Affiliation(s)
- Marcus V Pinto
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore
| | - Peng-Soon Ng
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore
| | - Benjamin M Howe
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore
| | - Ruple S Laughlin
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore
| | - Prabin Thapa
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore
| | - Peter J Dyck
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore.
| | - P James B Dyck
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore.
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Focal Limb Weakness. Neurology 2021. [DOI: 10.1007/978-3-030-55598-6_11] [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] Open
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Castiglione JI, Marrodan M, Alessandro L, Taratuto AL, Brand P, Nogués M, Barroso F. Vasculitic Peripheral Neuropathy, Differences Between Systemic and Non-Systemic Etiologies: A Case Series and Biopsy Report. J Neuromuscul Dis 2020; 8:155-161. [PMID: 33104037 DOI: 10.3233/jnd-200576] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Vasculitic peripheral neuropathy (VPN) is caused by vessel inflammation leading to peripheral nerve injury of acute-to-subacute onset. When VPN occurs in the context of systemic disease it is classified as Systemic Vasculitic Neuropathy (SVN) and as Non-Systemic Vasculitic Neuropathy (NSVN) when restricted to the nerves. OBJECTIVE This study aimed to compare the clinical characteristics, biopsy findings and disease outcome in patients with VPN. METHODS Clinical records of adult patients with VPN diagnosed at our institution between June-2002 and June-2019 were retrospectively reviewed. Demographic characteristics, clinical manifestations, nerve conduction studies, nerve biopsies, treatment and clinical evolution were analyzed in all patients with at least 6 months follow-up. RESULTS Twenty-five patients with VPN were included (SVN, n = 10; NSVN, n = 15). No significant differences in demographic or clinical features were found between groups. The median delay between symptom onset and nerve biopsy was significantly longer in NSVN patients (10 vs 5.5 months, p = 0.009). Erythrocyte sedimentation rate (ESR) values over 20 mm/h were significantly more common in SVN patients (100% vs. 60%, p = 0.024). Nerve biopsies showed active lesions more frequently in treatment-naive patients compared to those who had received at least 2 weeks of corticosteroids (92% vs 38%; p = 0.03), with a higher proportion of definite VPN cases (92 vs 46%; p = 0.04). CONCLUSIONS Although the clinical manifestations are similar, ESR is an important tool to help distinguish between both conditions. Early nerve biopsy in untreated patients increases diagnostic accuracy, avoiding misdiagnosis.
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Affiliation(s)
| | - M Marrodan
- Neurology department, FLENI, Buenos Aires, Argentina
| | - L Alessandro
- Neurology department, FLENI, Buenos Aires, Argentina
| | - A L Taratuto
- Neuropathology department, FLENI, Buenos Aires, Argentina
| | - P Brand
- Neurology department, FLENI, Buenos Aires, Argentina
| | - M Nogués
- Neurology department, FLENI, Buenos Aires, Argentina
| | - F Barroso
- Neurology department, FLENI, Buenos Aires, Argentina
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Abstract
There is an aging of the peripheral nervous system characterized by a decrease in sensory and motor nerve conduction, amplitudes of motor and above all sensory potentials, an abolition of the ankle jerk reflexes and an alteration of proprioceptive sensitivity in almost two-thirds of individuals over 65 years old. These anomalies tend to increase beyond 80 years. However, these signs of aging do not affect the quality of life of the subjects. The causes of peripheral neuropathies in the elderly differ little from those observed before age 65. Of course, hereditary causes are much less frequent, except cases with a late onset, now easily detectable, such as familial amyloidosis. In our climates and in the most developed countries, diabetes remains the most common cause, the prevalence of neuropathy increasing with age. The so-called idiopathic causes are also frequent and despite extensive investigations, nearly 20% of cases remain without etiological diagnosis, but this type of neuropathy is generally mild and not very progressive. The presence of peripheral neuropathy in the elderly can cause real problems in daily life, including the frequency of falls that can be responsible for deleterious bone damage.
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Affiliation(s)
- P Bouche
- Laboratory of Clinical Neurophysiology (Professor Lionel-Naccache), Salpetriere Hospital, 47, boulevard de l'hôpital, 75013 Paris, France.
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Update on classification, epidemiology, clinical phenotype and imaging of the nonsystemic vasculitic neuropathies. Curr Opin Neurol 2020; 32:684-695. [PMID: 31313704 DOI: 10.1097/wco.0000000000000727] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Single-organ vasculitis of the peripheral nervous system (PNS) is often designated nonsystemic vasculitic neuropathy (NSVN). Several variants or subtypes have been distinguished, including migratory sensory neuropathy, postsurgical inflammatory neuropathy, diabetic radiculoplexus neuropathies, skin-nerve vasculitides, and, arguably, neuralgic amyotrophy. NSVN often presents as nondiabetic lumbosacral radiculoplexus neuropathy (LRPN). This review updates classification, clinical features, epidemiology, and imaging of these disorders. RECENT FINDINGS A recent study showed the annual incidence of LRPN in Olmstead County, Minnesota to be 4.16/100 000:2.79/100 000 diabetic and 1.27/100 000 nondiabetic. This study was the first to determine the incidence or prevalence of any vasculitic neuropathy. In NSVN, ultrasonography shows multifocal enlargement of proximal and distal nerves. In neuralgic amyotrophy, MRI and ultrasound reveal multifocal enlargements and focal constrictions in nerves derived from the brachial plexus. Histopathology of these chronic lesions shows inflammation and rare vasculitis. Diffusion tensor imaging of tibial nerves in NSVN revealed decreased fractional anisotropy in one study. SUMMARY Single-organ PNS vasculitides are the most common inflammatory neuropathies. Neuralgic amyotrophy might result from PNS vasculitis, but further study is necessary. The usefulness of focal nerve enlargements or constrictions in understanding pathological mechanisms, directing biopsies, and monitoring disease activity in NSVN should be further investigated.
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Abstract
The systemic vasculitides are heterogeneous clinicopathologic disorders that share the common feature of vascular inflammation. The resulting disorder can vary depending on involvement of specific organs, caliber of blood vessels, the underlying inflammatory process, and individual host factors. The cumulative result is diminished blood flow, vascular alterations, and eventual occlusion with variable ischemia, necrosis, and tissue damage. An international revised nomenclature system provides the necessary nosology and findings relevant to classify each of the vasculitides. This article is an introduction and overview of the clinical presentation, differential diagnosis, laboratory evaluation, and treatment of systemic and nervous system vasculitides.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY 10016, USA; School of Public Health, City University of New York, New York, NY, USA.
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Reduced gene expression of netrin family members in skin and sural nerve specimens of patients with painful peripheral neuropathies. J Neurol 2019; 266:2812-2820. [PMID: 31392393 DOI: 10.1007/s00415-019-09496-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/02/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate the expression of axon guidance cues in skin and sural nerve biopsies of patients with polyneuropathies (PNP) as potential markers of nerve de- and regeneration and inflammation. METHODS We prospectively recruited 88 patients with PNP and compared data between patient subgroups and healthy controls. All patients underwent skin punch and/or sural nerve biopsy at the lower leg and proximal thigh. We characterized gene expression profiles of netrin family members as target genes involved in neuronal de- and regeneration [netrin 1, deleted in colorectal cancer (DCC), uncoordinated5H2, neogenin 1 (NEO1), netrin G1, netrin G2] using quantitative real-time PCR. RESULTS Gene expression of netrin 1 (p < 0.05 in proximal skin), DCC (p < 0.001 in distal skin), NEO1 (p < 0.05 in distal skin), netrin G1 (p < 0.05 in proximal and p < 0.01 in distal skin), and netrin G2 (p < 0.001 in distal skin) was lower in skin biopsies of patients with neuropathy compared to healthy controls. Gene expression of NEO1 (p < 0.05 in distal skin), netrin G2 (p < 0.05 in distal skin), and DCC (p < 0.05 in sural nerve) was lower in samples of patients with painful compared to painless PNP and also correlated positively with intraepidermal nerve fiber density. Skin and sural nerve gene expression of the investigated target genes did not differ between neuropathies of different etiologies. CONCLUSION We show reduced cutaneous and neural axon guide expression, which may contribute to a dysregulation of nerve fiber de- and regeneration.
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Hui M, Meena AK, Rajasekhar L, Sireesha Y, Afshan J, Mridula R, Borgohain R, Uppin MS. Vasculitic Neuropathy: A Retrospective Analysis of Nerve Biopsies and Clinical Features from a Single Tertiary Care Center. Ann Indian Acad Neurol 2019; 22:180-186. [PMID: 31007430 PMCID: PMC6472243 DOI: 10.4103/aian.aian_47_18] [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: 11/04/2022] Open
Abstract
Objective Vasculitic neuropathy can be either restricted to the peripheral nerves or associated with systemic involvement of other organs. The objective of this study was to analyze the nerve biopsies reported as "vasculitic neuropathy" with clinical features. Materials and Methods All cases diagnosed with vasculitic neuropathy were retrospectively analyzed and categorized as systemic vasculitis and nonsystemic vasculitic neuropathy based on the clinical features. The histological features were further evaluated and classified according to the Peripheral Nerve Society Guidelines. Results Of the 126 cases, there were 65 nonsystemic vasculitis, 45 secondary systemic vasculitis, and 16 primary systemic vasculitis. Definite vasculitis was more common in the systemic vasculitis group. The epineurial vessels were predominantly involved with chronic axonal changes. Conclusion The sensitivity of definite vasculitis on nerve biopsy was 54.76%. The sensitivity increases when the diagnostic criteria of definite and probable vasculitis were applied taking into account perivascular inflammation accompanied by vascular changes and axonopathy.
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Affiliation(s)
- Monalisa Hui
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - A K Meena
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Liza Rajasekhar
- Department of Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Yareeda Sireesha
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Jabeen Afshan
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rukmini Mridula
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Rupam Borgohain
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Megha S Uppin
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Shirai T, Shirota Y, Fujii H, Ishii T, Harigae H. Four distinct clinical phenotypes of vasculitis affecting medium-sized arteries. Scand J Rheumatol 2019; 48:308-314. [DOI: 10.1080/03009742.2018.1551965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- T Shirai
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Y Shirota
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - H Fujii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - T Ishii
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - H Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Langjahr M, Schubert AL, Sommer C, Üçeyler N. Increased pro-inflammatory cytokine gene expression in peripheral blood mononuclear cells of patients with polyneuropathies. J Neurol 2018; 265:618-627. [DOI: 10.1007/s00415-018-8748-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/24/2017] [Accepted: 01/10/2018] [Indexed: 12/13/2022]
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Vasculitic Neuropathy. Neuromuscul Disord 2018. [DOI: 10.1007/978-981-10-5361-0_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Takahashi M, Koike H, Ikeda S, Kawagashira Y, Iijima M, Hashizume A, Katsuno M, Sobue G. Distinct pathogenesis in nonsystemic vasculitic neuropathy and microscopic polyangiitis. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2017; 4:e407. [PMID: 29082297 PMCID: PMC5656408 DOI: 10.1212/nxi.0000000000000407] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 09/07/2017] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To investigate the mechanisms of vasculitis in nonsystemic vasculitic neuropathy (NSVN) and microscopic polyangiitis (MPA), focusing on complement- and antineutrophil cytoplasmic antibody (ANCA)-associated pathogenesis. METHODS Sural nerve biopsy specimens taken from twenty-four patients with NSVN and 37 with MPA-associated neuropathy (MPAN) were examined. Twenty-two patients in the MPAN group tested positive for ANCA. RESULTS Immunostaining for complement component C3d deposition showed more frequent positive staining of epineurial small vessels in NSVN than in MPAN (p = 0.002). The percentages of C3d-positive blood vessels were higher in the NSVN group than those in the ANCA-positive MPAN and ANCA-negative MPAN groups (p = 0.002 and p = 0.009, respectively). Attachment of neutrophils to the endothelial cells of epineurial small vessels was frequently observed in the MPAN groups, irrespective of the presence or absence of ANCA, but was scarce in the NSVN group. Immunohistochemistry using antimyeloperoxidase (MPO) antibodies revealed that the number of MPO-positive cells attached to the endothelial cells of epineurial vessels was lower in the NSVN group than that in the ANCA-positive MPAN and ANCA-negative MPAN groups (p < 0.001 and p = 0.011, respectively). CONCLUSIONS NSVN and MPA have distinct mechanisms of vasculitis. In MPA, the attachment of neutrophils to vascular endothelial cells seems to be an initial lesion of vasculitis, regardless of the presence or absence of ANCA. Complement participated in the pathogenesis of vasculitis in NSVN.
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Affiliation(s)
- Mie Takahashi
- Department of Neurology (M.T., H.K., S.I., Y.K., M.I., A.H., M.K., G.S.), and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Haruki Koike
- Department of Neurology (M.T., H.K., S.I., Y.K., M.I., A.H., M.K., G.S.), and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Shohei Ikeda
- Department of Neurology (M.T., H.K., S.I., Y.K., M.I., A.H., M.K., G.S.), and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Yuichi Kawagashira
- Department of Neurology (M.T., H.K., S.I., Y.K., M.I., A.H., M.K., G.S.), and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Masahiro Iijima
- Department of Neurology (M.T., H.K., S.I., Y.K., M.I., A.H., M.K., G.S.), and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Atsushi Hashizume
- Department of Neurology (M.T., H.K., S.I., Y.K., M.I., A.H., M.K., G.S.), and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Masahisa Katsuno
- Department of Neurology (M.T., H.K., S.I., Y.K., M.I., A.H., M.K., G.S.), and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
| | - Gen Sobue
- Department of Neurology (M.T., H.K., S.I., Y.K., M.I., A.H., M.K., G.S.), and Research Division of Dementia and Neurodegenerative Disease (G.S.), Nagoya University Graduate School of Medicine, Japan
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Schneider C, Wunderlich G, Bleistein J, Fink GR, Deckert M, Brunn A, Lehmann HC. Lymphocyte antigens targetable by monoclonal antibodies in non-systemic vasculitic neuropathy. J Neurol Neurosurg Psychiatry 2017; 88:756-760. [PMID: 28550073 DOI: 10.1136/jnnp-2017-315878] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/21/2017] [Accepted: 05/03/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To identify the most relevant antigens for monoclonal antibodies in lymphocytic infiltrates in non-systemic vasculitic neuropathy (NSVN). BACKGROUND Current immunosuppressive treatment for NSVN is insufficient. Monoclonal antibodies might be a treatment option, but the expression profile for targetable antigens on lymphocytic infiltrates in NSVN is unknown. METHODS Sural nerve biopsies from a cohort of patients with NSVN were immunohistochemically studied for the expression of potential candidate antigens in perivascular and intramural lymphocytic infiltrates and correlated with neurological and electrophysiological parameters. 20 patients with treatment naïve NSVN and 5 patients with idiopathic axonal neuropathy were included. RESULTS The CD52, BAFF and CD49d antigens were expressed in epineurial, perivascular or intramural lymphocytes of all (20/20) patients. CD52 was most prominently expressed in 21.49% of all inflammatory infiltrates. BAFF and CD49d were detected in 11.25% and 10.99% of these lymphocytes, respectively. The CD20, CD25 and CD126 antigens were found less frequently and at low levels only (CD20: 10/20 patients, 5.84% of lymphocytes; CD25: 17/20 patients, 5.22% of lymphocytes; CD126: 3/20 patients, 0.15% of lymphocytes). CONCLUSION This is the first study in NSVN that identifies antigens expressed by pathogenic lymphocytes, which are potential targets for future monoclonal antibody treatment. Our data suggest that NSVN is amenable to monoclonal antibodies and, moreover, that targeting CD52 may be particularly promising. Our results strongly warrant future clinical trials in NSVN with monoclonal antibodies.
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Affiliation(s)
| | | | | | - Gereon R Fink
- Department of Neurology, University of Cologne, Köln, Germany.,Institute of Neuroscience and Medicine (INM-3), Research Centre Juelich, Jülich, Germany
| | - Martina Deckert
- Department of Neuropathology, University of Cologne, Köln, Germany
| | - Anna Brunn
- Department of Neuropathology, University of Cologne, Köln, Germany
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Üçeyler N, Braunsdorf S, Kunze E, Riediger N, Scheytt S, Divisova Š, Bekircan‐kurt CE, Toyka KV, Sommer C. Cellular infiltrates in skin and sural nerve of patients with polyneuropathies. Muscle Nerve 2017; 55:884-893. [DOI: 10.1002/mus.25240] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 06/23/2016] [Accepted: 07/05/2016] [Indexed: 02/03/2023]
Affiliation(s)
- Nurcan Üçeyler
- Department of NeurologyUniversity of WürzburgJosef‐Schneider‐Strasse 1197080Würzburg Germany
| | - Silvia Braunsdorf
- Department of NeurologyUniversity of WürzburgJosef‐Schneider‐Strasse 1197080Würzburg Germany
| | - Ekkehard Kunze
- Department of NeurosurgeryUniversity of WürzburgWürzburg Germany
| | - Nadja Riediger
- Department of NeurologyUniversity of WürzburgJosef‐Schneider‐Strasse 1197080Würzburg Germany
| | - Sarah Scheytt
- Department of NeurologyUniversity of WürzburgJosef‐Schneider‐Strasse 1197080Würzburg Germany
| | - Šarka Divisova
- Department of NeurologyUniversity of WürzburgJosef‐Schneider‐Strasse 1197080Würzburg Germany
| | - Can Ebru Bekircan‐kurt
- Department of NeurologyUniversity of WürzburgJosef‐Schneider‐Strasse 1197080Würzburg Germany
| | - Klaus Viktor Toyka
- Department of NeurologyUniversity of WürzburgJosef‐Schneider‐Strasse 1197080Würzburg Germany
| | - Claudia Sommer
- Department of NeurologyUniversity of WürzburgJosef‐Schneider‐Strasse 1197080Würzburg Germany
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Illes Z, Blaabjerg M. Cerebrospinal fluid findings in Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2017; 146:125-138. [PMID: 29110767 DOI: 10.1016/b978-0-12-804279-3.00009-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The classic immunologic alteration of the cerebrospinal fluid (CSF) in Guillain-Barré syndrome (GBS), albuminocytologic dissociation, has been known since the original paper by Guillain, Barré, and Strohl. Albuminocytologic dissociation has been also described in other forms of the GBS spectrum, such as axonal motor or motor-sensory forms (AMAN, AMSAN), the anti-GQ1b spectrum of Miller Fisher syndrome, and Bickerstaff brainstem encephalitis. Cytokines, chemokines, antibodies, complement components, and molecules with a putative neuroprotective role or indicating axonal damage have also been examined using different methods. Besides these candidate approaches, proteomics has been recently applied to discover potential biomarkers. The overall results support the immunopathogenesis of GBS, but albuminocytologic dissociation remained the only consistent CSF biomarker supporting the diagnosis of GBS. Chronic inflammatory neuropathies also comprise a heterogeneous group of diseases. Increased protein in the CSF is a supportive factor of chronic inflammatory demyelinating polyneuropathy, especially in the absence of definite electrophysiologic criteria. A number of other markers have also been investigated in the CSF of patients with chronic inflammatory neuropathies, similar to GBS. However, none has been used in supporting diagnosis, differentiating among syndromes, or predicting the clinical course and treatment responses.
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Affiliation(s)
- Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Morten Blaabjerg
- Department of Neurology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Leupold D, Felbecker A, Tettenborn B, Hundsberger T. Nerve Ultrasound as a Decisive Tool in Nonsystemic Vasculitic Neuropathy: A Case Report. Case Rep Neurol 2016; 8:108-14. [PMID: 27403131 PMCID: PMC4924461 DOI: 10.1159/000446314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION The additional value of peripheral nerve ultrasound in acquired immune-mediated neuropathies has recently been reported. Its impact in vasculitic neuropathy is yet to be defined. We report electrophysiological and nerve ultrasound studies in a patient with nonsystemic vasculitic neuropathy at first diagnosis and in response to immunosuppression. CASE REPORT A 44-year-old female presented with painful neuropathy and weakness of the intrinsic hand muscles. Electrodiagnostic studies revealed severe axonal neuropathy of the nerves of the left arm. On nerve ultrasound, massive and patchy swelling of these nerves was detected. Clinical, laboratory, and radiological evidence of nonneuromuscular involvement and systemic vasculitic diseases was absent. Hence, nonsystemic vasculitic neuropathy was diagnosed without the possibility of histological verification. After 6 months of systemic immunosuppression with steroids and cyclophosphamide, clinical symptoms improved in parallel with neurosonography. In contrast, electrophysiological studies remained pathological despite clinical improvement. CONCLUSIONS Neurosonography studies in nonsystemic vasculitic neuropathy are rare but might be an ancillary technique to guide noninvasive diagnosis and therapeutic monitoring. Morphological analysis of nerves and changes in response to treatment could be well visualized. Additionally, neurosonography might be useful to target nerve biopsy.
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Affiliation(s)
- Daniela Leupold
- Departments of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Ansgar Felbecker
- Departments of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | | | - Thomas Hundsberger
- Departments of Neurology, Cantonal Hospital, St. Gallen, Switzerland; Departments of Haematology and Oncology, Cantonal Hospital, St. Gallen, Switzerland
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Goedee HS, van der Pol WL, van Asseldonk JTH, Vrancken AFJE, Notermans NC, Visser LH, van den Berg LH. Nerve sonography to detect peripheral nerve involvement in vasculitis syndromes. Neurol Clin Pract 2016; 6:293-303. [PMID: 29443128 DOI: 10.1212/cpj.0000000000000258] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background We sought to determine the usefulness of sonography in the detection of nerve involvement in patients with vasculitic neuropathy. Methods We enrolled 16 consecutive patients with vasculitic neuropathy (11 systemic vasculitis and 5 single organ peripheral nerve vasculitis), who met the diagnostic criteria of the Peripheral Nerve Society, and 16 disease controls with noninflammatory axonal polyneuropathy (10 cryptogenic, 4 metabolic, 2 hereditary). Patients underwent standardized nerve conduction studies and assessment of muscle strength (Medical Research Council scale), in addition to sonography of large arm and leg nerves, and brachial plexus. Nerves were evaluated bilaterally at predetermined sites for nerve size (cross-sectional area) and presence of hypervascularization. Results We found enlarged nerves at common sites of nerve compression in all vasculitic and control patients. Multifocal enlargement in arm nerves, proximal to common sites of nerve compression, was sensitive (94%) and specific (88%) for vasculitic neuropathy. Sonography showed nerve enlargement in 51% of clinically or electrodiagnostically unaffected nerves. Sonography of the brachial plexus was normal. We found hypervascularization in 3 patients with systemic vasculitis. Conclusions Sonographic enlargement of arm nerves proximal to sites of nerve compression with sparing of the brachial plexus may indicate a pattern characteristic of patients with vasculitic neuropathy. Sonography may represent a sensitive and specific technique for the detection of inflammatory neuropathy. Classification of evidence This study provides Class III evidence that sonographic enlargement of arm nerves proximal to sites of nerve compression accurately identifies patients with vasculitic neuropathy.
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Affiliation(s)
- H Stephan Goedee
- Department of Neurology (HSG, WLvdP, AFJEV, NCN, LHvdB), Brain Centre Rudolf Magnus, UMC Utrecht; and Department of Neurology and Clinical Neurophysiology (J-THvA, LHV), St. Elisabeth Hospital, Tilburg, the Netherlands
| | - W Ludo van der Pol
- Department of Neurology (HSG, WLvdP, AFJEV, NCN, LHvdB), Brain Centre Rudolf Magnus, UMC Utrecht; and Department of Neurology and Clinical Neurophysiology (J-THvA, LHV), St. Elisabeth Hospital, Tilburg, the Netherlands
| | - Jan-Thies H van Asseldonk
- Department of Neurology (HSG, WLvdP, AFJEV, NCN, LHvdB), Brain Centre Rudolf Magnus, UMC Utrecht; and Department of Neurology and Clinical Neurophysiology (J-THvA, LHV), St. Elisabeth Hospital, Tilburg, the Netherlands
| | - Alexander F J E Vrancken
- Department of Neurology (HSG, WLvdP, AFJEV, NCN, LHvdB), Brain Centre Rudolf Magnus, UMC Utrecht; and Department of Neurology and Clinical Neurophysiology (J-THvA, LHV), St. Elisabeth Hospital, Tilburg, the Netherlands
| | - Nicolette C Notermans
- Department of Neurology (HSG, WLvdP, AFJEV, NCN, LHvdB), Brain Centre Rudolf Magnus, UMC Utrecht; and Department of Neurology and Clinical Neurophysiology (J-THvA, LHV), St. Elisabeth Hospital, Tilburg, the Netherlands
| | - Leo H Visser
- Department of Neurology (HSG, WLvdP, AFJEV, NCN, LHvdB), Brain Centre Rudolf Magnus, UMC Utrecht; and Department of Neurology and Clinical Neurophysiology (J-THvA, LHV), St. Elisabeth Hospital, Tilburg, the Netherlands
| | - Leonard H van den Berg
- Department of Neurology (HSG, WLvdP, AFJEV, NCN, LHvdB), Brain Centre Rudolf Magnus, UMC Utrecht; and Department of Neurology and Clinical Neurophysiology (J-THvA, LHV), St. Elisabeth Hospital, Tilburg, the Netherlands
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Callaghan BC, Price RS, Chen KS, Feldman EL. The Importance of Rare Subtypes in Diagnosis and Treatment of Peripheral Neuropathy: A Review. JAMA Neurol 2016; 72:1510-8. [PMID: 26437251 DOI: 10.1001/jamaneurol.2015.2347] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Peripheral neuropathy is a prevalent condition that usually warrants a thorough history and examination but has limited diagnostic evaluation. However, rare localizations of peripheral neuropathy often require more extensive diagnostic testing and different treatments. OBJECTIVE To describe rare localizations of peripheral neuropathy, including the appropriate diagnostic evaluation and available treatments. EVIDENCE REVIEW References were identified from PubMed searches conducted on May 29, 2015, with an emphasis on systematic reviews and randomized clinical trials. Articles were also identified through the use of the authors' own files. Search terms included common rare neuropathy localizations and their causes, as well as epidemiology, pathophysiology, diagnosis, and treatment. FINDINGS Diffuse, nonlength-dependent neuropathies, multiple mononeuropathies, polyradiculopathies, plexopathies, and radiculoplexus neuropathies are rare peripheral neuropathy localizations that often require extensive diagnostic testing. Atypical neuropathy features, such as acute/subacute onset, asymmetry, and/or motor predominant signs, are frequently present. The most common diffuse, nonlength-dependent neuropathies are Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and amyotrophic lateral sclerosis. Effective disease-modifying therapies exist for many diffuse, nonlength-dependent neuropathies including Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and some paraprotein-associated demyelinating neuropathies. Vasculitic neuropathy (multiple mononeuropathy) also has efficacious treatment options, but definitive evidence of a treatment effect for IgM anti-MAG neuropathy and diabetic amyotrophy (radiculoplexus neuropathy) is lacking. CONCLUSIONS AND RELEVANCE Recognition of rare localizations of peripheral neuropathy is essential given the implications for diagnostic testing and treatment. Electrodiagnostic studies are an important early step in the diagnostic evaluation and provide information on the localization and pathophysiology of nerve injury.
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Affiliation(s)
| | - Raymond S Price
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Kevin S Chen
- Department of Neurosurgery, University of Michigan, Ann Arbor
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor
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Fujikawa S, Omoto M, Ogasawara JI, Koga M, Kawai M, Kanda T. [Systemic vasculitic neuropathy diagnosed by means of (18)F-FDG PET CT]. Rinsho Shinkeigaku 2016; 56:88-92. [PMID: 26797481 DOI: 10.5692/clinicalneurol.cn-000803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We report a 43-year-old man experienced numbness in the distal portion of both legs, which progressed over following two months. Neurological examination showed hypesthesia and muscle weakness in the distal portion of both legs. No abnormal findings were seen on blood test and whole-body contrast enhanced computed tomography (CT). Histopathological findings of the sural nerve and the peroneus brevis muscle showed decreased myelinated nerve fibers with scattered myelin ovoids, vascular occlusion in the epineurium, and inflammatory cell around the arteriole in the muscle bundle. These findings suggested falling in the category as non-systemic vasculitic neuropathy (NSVN). (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) revealed the increase of FDG uptake in the rectum. Inflammatory cell infiltration was found around the arteriole with fibrinoid necrosis in the histopathological specimen of the rectal mucosal biopsy. This result represented the diagnosis as systemic vasculitis. The diagnosis of NSVN may depend on the sensitivity of diagnostic procedure, and (18)F-FDG PET CT might be a useful tool to detect small or medium-sized vasculitis.
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Affiliation(s)
- Susumu Fujikawa
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
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Focal Limb Weakness. Neurology 2016. [DOI: 10.1007/978-3-319-29632-6_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Hadden RDM, Collins MP, Živković SA, Hsieh ST, Bonetto C, Felicetti P, Marchione P, Santuccio C, Bonhoeffer J. Vasculitic peripheral neuropathy: Case definition and guidelines for collection, analysis, and presentation of immunisation safety data. Vaccine 2015; 35:1567-1578. [PMID: 26655629 DOI: 10.1016/j.vaccine.2015.11.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 11/16/2015] [Indexed: 12/13/2022]
Affiliation(s)
| | | | - Saša A Živković
- Department of Neurology, University of Pittsburgh Medical Center, USA
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital, Taiwan
| | | | | | | | | | - Jan Bonhoeffer
- Brighton Collaboration Foundation, Basel, Switzerland; University of Basel Children's Hospital, Basel, Switzerland
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Neuropatie delle vasculiti. Neurologia 2015. [DOI: 10.1016/s1634-7072(15)73992-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
The international standard of nomenclature and classification in vasculitis, CHCC 1994,was revised as CHCC 2012. In the first part of this review article I briefly summarized the CHCC 2012 and pointed out the changes in this revision, especially on the disorders related to vasculitic neuropathy. Notable changes include the introduction of new terms such as granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis. In the second part, I mentioned the tips for the diagnosis and treatment of vasculitic neuropathy. Because most of the vasculitic neuropathy patients require rigorous, long-standing immunosuppressive therapy, the accurate diagnosis based on the pathological detection of vasculitic changes is mandatory. In this regard, the value of sural nerve biopsy is still not ignorable. In the treatment of vascultic neuropathy, there are no controlled treatment trials and clinical practice is guided by experience from case series and indirectly by analogy with systemic vasculitis. Although combined therapy using prednisolone and cyclophosphamide is usually recommended by experts, tailor-made treatment regimen based on the conditions of each patient would produce the best outcome in vasculitic neuropathy.
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Affiliation(s)
- Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
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Lubana SS, Singh N, Sanelli-Russo S, Abrudescu A. Non-Systemic Vasculitic Neuropathy: An Enigmatic Clinical Entity. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:449-53. [PMID: 26167722 PMCID: PMC4504409 DOI: 10.12659/ajcr.894601] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 06/28/2015] [Indexed: 12/02/2022]
Abstract
BACKGROUND Non-systemic vasculitic peripheral neuropathy is a rare condition characterized by necrotizing inflammation resulting in luminal narrowing of the vasa nervorum, leading to ischemic injury to peripheral nerves. Here, we present the case of 63-year-old woman with subacute onset of severe hyperesthesia of the lower extremities accompanied by foot drop. CASE REPORT A 63-year-old woman with prolonged history of uncontrolled diabetes mellitus presented with subacute onset of severe bilateral lower extremity hyperesthesia and motor weakness along with left-sided foot drop. She had multiple emergency room visits with no relief of her symptoms. High doses of analgesics were insufficient to control pain. Laboratory tests were positive only for high erythrocyte sedimentation rate and C-reactive protein. A skin biopsy obtained 5 cm above the left lateral malleolus revealed medium-sized dermal vasculitis with dense mononuclear infiltrate. Electromyography showed peripheral neuropathy. A nerve biopsy was needed to reveal the exact diagnosis. CONCLUSIONS Diagnosis of non-systemic vasculitic peripheral neuropathy can be delayed or missed in patients with uncontrolled diabetes mellitus, leading to significant morbidity. Elevated markers of inflammation in the absence of a possible explanation should prompt the clinician to perform a nerve biopsy; however, it is an invasive procedure and is associated with complications of post-neuropathic pain and delayed wound healing. Magnetic resonance angiography of the lower limbs, if combined with skin biopsy, can save the patient from undergoing nerve biopsy.
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Affiliation(s)
- Sandeep Singh Lubana
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Queens, NY,U.S.A
| | - Navdeep Singh
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Queens, NY,U.S.A
| | - Susan Sanelli-Russo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Queens, NY, U.S.A
| | - Adriana Abrudescu
- Department of Rheumatology, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Queens, NY, U.S.A
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Üçeyler N, Geng A, Reiners K, Toyka KV, Sommer C. Non-systemic vasculitic neuropathy: single-center follow-up of 60 patients. J Neurol 2015; 262:2092-100. [DOI: 10.1007/s00415-015-7813-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/03/2015] [Accepted: 06/04/2015] [Indexed: 10/23/2022]
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Blaes F. Diagnosis and therapeutic options for peripheral vasculitic neuropathy. Ther Adv Musculoskelet Dis 2015; 7:45-55. [PMID: 25829955 PMCID: PMC4357592 DOI: 10.1177/1759720x14566617] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Vasculitis can affect the peripheral nervous system alone (nonsystemic vasculitic neuropathy) or can be a part of primary or secondary systemic vasculitis. In cases of pre-existing systemic vasculitis, the diagnosis can easily be made, whereas suspected vasculitic neuropathy as initial or only manifestation of vasculitis requires careful clinical, neurophysiological, laboratory and histopathological workout. The typical clinical syndrome is mononeuropathia multiplex or asymmetric neuropathy, but distal-symmetric neuropathy can frequently be seen. Standard treatments include steroids, azathioprine, methotrexate and cyclophosphamide. More recently the B-cell antibody rituximab and intravenous immunoglobulins have shown to be effective in some vasculitic neuropathy types.
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Affiliation(s)
- Franz Blaes
- Department of Neurology, KKH Gummersbach, Wilhelm-Breckow-Allee 20, 51643 Gummersbach, Germany
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Anish L, Nagappa M, Mahadevan A, Taly AB. Neuropathy in elderly: lessons learnt from nerve biopsy. Age Ageing 2015; 44:312-7. [PMID: 25362502 DOI: 10.1093/ageing/afu171] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To study the utility of nerve biopsy in providing diagnostic, therapeutic or prognostic information that aid in clinical management in elderly subjects with peripheral neuropathy. METHODS Clinico-pathological data of 100 elderly subjects aged 65 and above with peripheral neuropathy who underwent nerve biopsy in the last decade (2002-2011) was reviewed. RESULTS The study included 100 subjects (M:F 78:22). Mean age at biopsy and symptom duration was 69.62±4.8 years and 24.17±40.4 months, respectively. The most common pattern of was distal symmetric sensorimotor polyneuropathy (35%), followed by multiple mononeuropathy (29%) and asymmetric sensorimotor neuropathy (15%). The nerve biopsy was 'diagnostic' in 24%, (definite vasculitis in 12, leprosy in 10 and acute inflammatory demyelinating polyradiculoneuropathy in 2) and proved 'essential' or 'helpful' in therapeutic management in 81% subjects. In 60 (60%) patients, where a pre-biopsy aetiological diagnosis could be arrived at based on the available data, nerve biopsy confirmed the diagnosis in 29 of 60 (48.3%), and offered a new diagnosis in 25 (41.7%). A higher yield of biopsy was noted in subjects with asymmetric/multiple mononeuropathy compared with symmetric neuropathies (32.7% versus 17.7%). In 40 (40%) patients without a pre-biopsy aetiological diagnosis, nerve biopsy was 'essential' in 7 of 40 (17.5%) as it provided a definitive diagnosis (definite vasculitis: 5, leprosy: 2), and 'helpful' in 21 of 40 (52.5%) (ischaemic neuropathy: 10, possible vasculitis: 9, probable vasculitis: 2). CONCLUSION Nerve biopsy aided in the detection of potentially treatable disorders and influenced patient management in a significant proportion of elderly subjects with peripheral neuropathy (81%), particularly in subset with undiagnosed neuropathies confirming that it's a useful tool in diagnosis of neuropathy in the elderly. With minor differences, the aetiological profile in our biopsied neuropathic elderly subjects may reflect the findings in other similar cohorts.
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Affiliation(s)
- Lawrence Anish
- Department of Neurology, NIMHANS, Bangalore, Karnataka 560029, India
| | - Madhu Nagappa
- Department of Neurology, NIMHANS, Bangalore, Karnataka 560029, India
| | - Anita Mahadevan
- Department of Neuropathology, NIMHANS, Bangalore, Karnataka, India
| | - Arun B Taly
- Department of Neurology, NIMHANS, Bangalore, Karnataka 560029, India
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Collins MP, Hadden RDM. Comments on 'gait disturbance due to foot drop is refractory to treatment in nonsystemic vasculitic neuropathy'. Eur Neurol 2014; 73:78-9. [PMID: 25401384 DOI: 10.1159/000368224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 09/07/2014] [Indexed: 11/19/2022]
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Abstract
The vasculitic neuropathies are a diverse group of disorders characterised by the acute-to-subacute onset of painful sensory and motor deficits that result from inflammatory destruction of nerve blood vessels and subsequent ischaemic injury. They are common in patients with primary systemic vasculitis and are seen in vasculitis secondary to disorders such as rheumatoid arthritis, viral infections, and diabetic inflammatory neuropathies. It is imperative that neurologists recognise these disorders to initiate treatment promptly and thereby prevent morbidity and mortality. To simplify the approach to patients with vasculitis of the peripheral nerves, a straightforward, dichotomous classification scheme can be used in which the vasculitic neuropathies are divided into two groups-nerve large arteriole vasculitis and nerve microvasculitis-on the basis of the size of the involved vessels. The size of the affected blood vessels correlates with the clinical course and prognosis in patients with vasculitic neuropathy.
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Hirahara T, Yamashita S, Misumi Y, Kawakami K, Hori H, Honda S, Watanabe M, Ikeda T, Yamashita T, Maeda Y, Ando Y. Gait Disturbance due to Foot Drop Is Refractory to Treatment in Nonsystemic Vasculitic Neuropathy. Eur Neurol 2014; 71:180-6. [DOI: 10.1159/000355531] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 09/08/2013] [Indexed: 11/19/2022]
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Lozeron P, Lacroix C, Michon M, Theaudin M, Petit Lacour MC, Denier C, Adams D. Vasculitis neuropathy mimicking lower limb mono-radiculopathy: a study and follow-up of 8 cases. Intern Emerg Med 2013; 8:601-9. [PMID: 23054406 DOI: 10.1007/s11739-012-0858-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 09/15/2012] [Indexed: 11/28/2022]
Abstract
The aim of this study was to describe misleading lower limb mono radiculopathy revealing peripheral nerve vasculitis. Retrospective review of eight patients with biopsy confirmed vasculitis presenting as mono-radicululopathy in a tertiary referral centre dedicated to patients with rare peripheral neuropathies. Patients presented with chronic (6/8) or acute (n = 2) radiculopathy in L4, L5 or S1 territories associated with subtle systemic signs. A diagnostic workup was performed because of secondary motor deficit, the absence of clear radicular compression or failure of initial treatment focused on pain relief. In all, nerve conduction studies showed signs of asymmetrical axonal peripheral neuropathy (mononeuritis multiplex). Necrotizing vasculitis was eventually confirmed by peripheral nerve biopsy. Biological markers of inflammation or eosinophilia were present in 5/8 and a progressive motor deficit (7/8) is suggestive of the diagnosis. Under steroid treatment, all patients improved during a mean of 2 years 6 months of follow-up (Mean Rankin score improvement 1.9 point), but five relapsed including three mononeuritis multiplex, and one had acral necrosis. Vasculitis presenting as LL radiculopathy is rare; EMG studies with signs of mononeuritis multiplex and nerve biopsy studies are useful for making the diagnosis.
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Affiliation(s)
- Pierre Lozeron
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, University Paris-Sud, Paris, France,
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Mikell CB, Chan AK, Stein GE, Tanji K, Winfree CJ. Muscle and nerve biopsies: techniques for the neurologist and neurosurgeon. Clin Neurol Neurosurg 2013; 115:1206-14. [PMID: 23769866 DOI: 10.1016/j.clineuro.2013.05.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 04/21/2013] [Accepted: 05/05/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Muscle and nerve biopsies are commonly performed procedures for the diagnosis of neuromuscular disorders. Neurologists and neurosurgeons are often consulted to perform these procedures in clinical practice. We provide guidelines in the performance of muscle and nerve biopsies. METHODS We describe the technique for performance of muscle and nerve biopsy, and review the relevant literature. RESULTS The quadriceps muscle is the most typical biopsy site for most myopathies, whereas the sural nerve is the most common nerve biopsy site for most peripheral neuropathies. Other sites may be utilized depending upon the pattern of symptoms or the differential diagnosis. Motor nerves may be sampled in the setting of motor neuron disease, for example. We advocate the use of conduit repair to allow for sensory or motor recovery to occur following nerve biopsy. CONCLUSION The muscle biopsy and nerve biopsy may be performed with high yield, low morbidity, and rare complications.
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Affiliation(s)
- Charles B Mikell
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA.
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