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Mountford R, Adler BL, Andersson D, Bashford-Rogers R, Berwick R, Bevan S, Caro X, Chung TH, Clark JD, Dawes JM, Dong X, Helyes Z, Kingery W, van Middendorp JJ, Neiland H, Maurer M, Scheibenbogen C, Schmack K, Schreiner T, Svensson CI, Tékus V, Goebel A. Antibody-mediated autoimmunity in symptom-based disorders: position statement and proceedings from an international workshop. Pain Rep 2024; 9:e1167. [PMID: 38873615 PMCID: PMC11175924 DOI: 10.1097/pr9.0000000000001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/03/2024] [Accepted: 04/06/2024] [Indexed: 06/15/2024] Open
Abstract
A 2-day closed workshop was held in Liverpool, United Kingdom, to discuss the results of research concerning symptom-based disorders (SBDs) caused by autoantibodies, share technical knowledge, and consider future plans. Twenty-two speakers and 14 additional participants attended. This workshop set out to consolidate knowledge about the contribution of autoantibodies to SBDs. Persuasive evidence for a causative role of autoantibodies in disease often derives from experimental "passive transfer" approaches, as first established in neurological research. Here, serum immunoglobulin (IgM or IgG) is purified from donated blood and transferred to rodents, either systemically or intrathecally. Rodents are then assessed for the expression of phenotypes resembling the human condition; successful phenotype transfer is considered supportive of or proof for autoimmune pathology. Workshop participants discussed passive transfer models and wider evidence for autoantibody contribution to a range of SBDs. Clinical trials testing autoantibody reduction were presented. Cornerstones of both experimental approaches and clinical trial parameters in this field were distilled and presented in this article. Mounting evidence suggests that immunoglobulin transfer from patient donors often induces the respective SBD phenotype in rodents. Understanding antibody binding epitopes and downstream mechanisms will require substantial research efforts, but treatments to reduce antibody titres can already now be evaluated.
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Affiliation(s)
- Rebecca Mountford
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Brittany L. Adler
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - David Andersson
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | | | - Richard Berwick
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Stuart Bevan
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Xavier Caro
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Tae Hwan Chung
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - J. David Clark
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - John M. Dawes
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Xinzhong Dong
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Zsuzsanna Helyes
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Wade Kingery
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | | | - Harvey Neiland
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Margot Maurer
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | | | - Katharina Schmack
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Thomas Schreiner
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | | | - Valéria Tékus
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Andreas Goebel
- Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
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2
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Nakane S, Matsuo H, Nakatsuji Y. Immunological and therapeutic insights in autoimmune autonomic ganglionopathy: What is the position of apheresis in immunotherapy? Transfus Apher Sci 2024; 63:103967. [PMID: 38959810 DOI: 10.1016/j.transci.2024.103967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
Autoimmune autonomic ganglionopathy (AAG) is characterized by various autonomic and extra-autonomic symptoms and is caused by autoantibodies against nicotinic acetylcholine receptors present in the autonomic ganglia (ganglionic acetylcholine receptor, gAChR), requiring immediate and aggressive intervention to prevent the exacerbation of symptoms. However, there is currently no internationally accepted standard of care for the immunotherapy of AAG, including apheresis. Although the rationale for the use of plasma exchange (PLEX) in AAG is strong, whereby pathogenic gAChR antibodies are removed, its overall impact on patient outcomes is not well-established. Based on previous case reports and small case series studies, we provide a comprehensive overview of the challenges and uncertainties surrounding the use of PLEX for the management of AAG and provide current practice recommendations to guide treatment decisions.
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Affiliation(s)
- Shunya Nakane
- Department of Neurology, Faculty of Medicine, University of Toyama, Toyama, Japan.
| | - Hidenori Matsuo
- Department of Neurology, National Hospital Organization Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Yuji Nakatsuji
- Department of Neurology, Faculty of Medicine, University of Toyama, Toyama, Japan
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3
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Alberti C, Spagliardi J, Barbic F, Doneddu PE, Cutellè C, Furlan R, Nobile-Orazio E. Autonomic neuropathy improving after intravenous immunoglobulin therapy. Clin Auton Res 2024; 34:311-316. [PMID: 38733551 DOI: 10.1007/s10286-024-01034-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 04/23/2024] [Indexed: 05/13/2024]
Affiliation(s)
- Claudia Alberti
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Jacopo Spagliardi
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Franca Barbic
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy
- Department of Internal Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy.
| | - Claudia Cutellè
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy
- Department of Internal Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, Milan University, Milan, Italy
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4
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Nakane S, Koike H, Hayashi T, Nakatsuji Y. Autoimmune Autonomic Neuropathy: From Pathogenesis to Diagnosis. Int J Mol Sci 2024; 25:2296. [PMID: 38396973 PMCID: PMC10889307 DOI: 10.3390/ijms25042296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
Autoimmune autonomic ganglionopathy (AAG) is a disease of autonomic failure caused by ganglionic acetylcholine receptor (gAChR) autoantibodies. Although the detection of autoantibodies is important for distinguishing the disease from other neuropathies that present with autonomic dysfunction, other factors are important for accurate diagnosis. Here, we provide a comprehensive review of the clinical features of AAG, highlighting differences in clinical course, clinical presentation, and laboratory findings from other neuropathies presenting with autonomic symptoms. The first step in diagnosing AAG is careful history taking, which should reveal whether the mode of onset is acute or chronic, followed by an examination of the time course of disease progression, including the presentation of autonomic and extra-autonomic symptoms. AAG is a neuropathy that should be differentiated from other neuropathies when the patient presents with autonomic dysfunction. Immune-mediated neuropathies, such as acute autonomic sensory neuropathy, are sometimes difficult to differentiate, and therefore, differences in clinical and laboratory findings should be well understood. Other non-neuropathic conditions, such as postural orthostatic tachycardia syndrome, chronic fatigue syndrome, and long COVID, also present with symptoms similar to those of AAG. Although often challenging, efforts should be made to differentiate among the disease candidates.
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Affiliation(s)
- Shunya Nakane
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Haruki Koike
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga 849-8501, Japan
| | - Tomohiro Hayashi
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Yuji Nakatsuji
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
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5
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Villagrán-García M, Farina A, Campetella L, Arzalluz-Luque J, Honnorat J. Autonomic nervous system involvement in autoimmune encephalitis and paraneoplastic neurological syndromes. Rev Neurol (Paris) 2024; 180:107-116. [PMID: 38142198 DOI: 10.1016/j.neurol.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/25/2023]
Abstract
In autoimmune neurological diseases, the autonomic nervous system can be the primary target of autoimmunity (e.g. autoimmune autonomic ganglionopathy), or, more frequently, be damaged together with other areas of the nervous system (e.g. Guillain-Barré syndrome). Patients with autoimmune encephalitis and paraneoplastic neurological syndromes (PNS) often develop dysautonomia; however, the frequency and spectrum of autonomic signs and symptoms remain ill defined except for those scenarios in which dysautonomia is a core feature of the disease. Such is the case of Lambert-Eaton myasthenic syndrome, Morvan syndrome or anti-NMDAR encephalitis; in the latter, patients with dysautonomia have been reported to carry a more severe disease and to retain higher disability than those without autonomic dysfunction. Likewise, the presence of autonomic involvement indicates a higher risk of death due to neurological cause in patients with anti-Hu PNS. However, in anti-Hu and other PNS, as well as in the context of immune checkpoint inhibitors' toxicities, the characterization of autonomic involvement is frequently overshadowed by the severity of other neurological symptoms and signs. When evaluated with tests specific for autonomic function, patients with autoimmune encephalitis or PNS usually show a more widespread autonomic involvement than clinically suggested, which may reflect a potential gap of care when it comes to diagnosing dysautonomia. This review aims to revise the autonomic involvement in patients with autoimmune encephalitis and PNS, using for that purpose an antibody-based approach. We also discuss and provide general recommendations for the evaluation and management of dysautonomia in these patients.
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Affiliation(s)
- M Villagrán-García
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France
| | - A Farina
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France; Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence, Italy
| | - L Campetella
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France
| | - J Arzalluz-Luque
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - J Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France.
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6
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Golden EP, Vernino S. Paraneoplastic autonomic neuropathies and GI dysmotility. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:275-282. [PMID: 38494282 DOI: 10.1016/b978-0-12-823912-4.00005-0] [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: 03/19/2024]
Abstract
A number of the well-recognized autoimmune and paraneoplastic neurologic syndromes commonly involve the autonomic nervous system. In some cases, the autonomic nerves or ganglia are primary targets of neurologic autoimmunity, as in immune-mediated autonomic ganglionopathies. In other disorders such as encephalitis, autonomic centers in the brain may be affected. The presence of autonomic dysfunction (especially gastrointestinal dysmotility) is sometimes overlooked even though this may contribute significantly to the symptom burden in these paraneoplastic disorders. Additionally, recognition of autonomic features as part of the clinical syndrome can help point the diagnostic evaluation toward autoimmune and paraneoplastic etiologies. As with other paraneoplastic disorders, the clinical syndrome and the presence and type of neurologic autoantibodies help to secure the diagnosis and direct the most appropriate investigation for malignancy. Optimal management for these conditions typically includes aggressive treatment of the neoplasm, immunomodulatory therapy, and symptomatic treatments for orthostatic hypotension and gastrointestinal dysmotility.
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Affiliation(s)
- Elisabeth P Golden
- Department of Medicine, Neurology Section, UT Health Science Center at Tyler, Tyler, TX, United States
| | - Steven Vernino
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, United States.
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7
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Tavee J, Brannagan TH, Lenihan MW, Muppidi S, Kellermeyer L, D Donofrio P. Updated consensus statement: Intravenous immunoglobulin in the treatment of neuromuscular disorders report of the AANEM ad hoc committee. Muscle Nerve 2023; 68:356-374. [PMID: 37432872 DOI: 10.1002/mus.27922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/05/2023] [Indexed: 07/13/2023]
Abstract
Intravenous immune globulin (IVIG) is an immune-modulating biologic therapy that is increasingly being used in neuromuscular disorders despite the paucity of high-quality evidence for various specific diseases. To address this, the AANEM created the 2009 consensus statement to provide guidance on the use of IVIG in neuromuscular disorders. Since then, there have been several randomized controlled trials for IVIG, a new FDA-approved indication for dermatomyositis and a revised classification system for myositis, prompting the AANEM to convene an ad hoc panel to update the existing guidelines.New recommendations based on an updated systemic review of the literature were categorized as Class I-IV. Based on Class I evidence, IVIG is recommended in the treatment of chronic inflammatory demyelinating polyneuropathy, Guillain-Barré Syndrome (GBS) in adults, multifocal motor neuropathy, dermatomyositis, stiff-person syndrome and myasthenia gravis exacerbations but not stable disease. Based on Class II evidence, IVIG is also recommended for Lambert-Eaton myasthenic syndrome and pediatric GBS. In contrast, based on Class I evidence, IVIG is not recommended for inclusion body myositis, post-polio syndrome, IgM paraproteinemic neuropathy and small fiber neuropathy that is idiopathic or associated with tri-sulfated heparin disaccharide or fibroblast growth factor receptor-3 autoantibodies. Although only Class IV evidence exists for IVIG use in necrotizing autoimmune myopathy, it should be considered for anti-hydroxy-3-methyl-glutaryl-coenzyme A reductase myositis given the risk of long-term disability. Insufficient evidence exists for the use of IVIG in Miller-Fisher syndrome, IgG and IgA paraproteinemic neuropathy, autonomic neuropathy, chronic autoimmune neuropathy, polymyositis, idiopathic brachial plexopathy and diabetic lumbosacral radiculoplexopathy.
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Affiliation(s)
- Jinny Tavee
- National Jewish Health, Division of Neurology, Denver, Colorado, USA
| | - Thomas H Brannagan
- Vagelos College of Physicians and Surgeons, Neurological Institute, Columbia University, New York, New York, USA
| | | | - Sri Muppidi
- Stanford Neuroscience Health Center, Palo Alto, California, USA
| | | | - Peter D Donofrio
- Neurology Clinic, Vanderbilt University, Nashville, Tennessee, USA
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8
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Younger DS. Autonomic failure: Clinicopathologic, physiologic, and genetic aspects. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:55-102. [PMID: 37562886 DOI: 10.1016/b978-0-323-98818-6.00020-0] [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: 08/12/2023]
Abstract
Over the past century, generations of neuroscientists, pathologists, and clinicians have elucidated the underlying causes of autonomic failure found in neurodegenerative, inherited, and antibody-mediated autoimmune disorders, each with pathognomonic clinicopathologic features. Autonomic failure affects central autonomic nervous system components in the α-synucleinopathy, multiple system atrophy, characterized clinically by levodopa-unresponsive parkinsonism or cerebellar ataxia, and pathologically by argyrophilic glial cytoplasmic inclusions (GCIs). Two other central neurodegenerative disorders, pure autonomic failure characterized clinically by deficits in norepinephrine synthesis and release from peripheral sympathetic nerve terminals; and Parkinson's disease, with early and widespread autonomic deficits independent of the loss of striatal dopamine terminals, both express Lewy pathology. The rare congenital disorder, hereditary sensory, and autonomic neuropathy type III (or Riley-Day, familial dysautonomia) causes life-threatening autonomic failure due to a genetic mutation that results in loss of functioning baroreceptors, effectively separating afferent mechanosensing neurons from the brain. Autoimmune autonomic ganglionopathy caused by autoantibodies targeting ganglionic α3-acetylcholine receptors instead presents with subacute isolated autonomic failure affecting sympathetic, parasympathetic, and enteric nervous system function in various combinations. This chapter is an overview of these major autonomic disorders with an emphasis on their historical background, neuropathological features, etiopathogenesis, diagnosis, and treatment.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Rowe S, Spies JM, Urriola N. Severe treatment-refractory antibody positive autoimmune autonomic ganglionopathy after mRNA COVID19 vaccination. Clin Exp Rheumatol 2022; 21:103201. [PMID: 36210629 PMCID: PMC9484853 DOI: 10.1016/j.autrev.2022.103201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND COVID-19 vaccine-associated peripheral and central neuroimmunological disorders have been well described. We present the case of a 56 year old male who developed α3-ganglionic AChR antibody positive Autoimmune Autonomic Ganglionopathy (AAG) after completion of a two-dose course of mRNA (Comirnaty) vaccination for COVID19. RESULTS A previously hypertensive 56 year old male presented with the subacute onset of severe constipation, urinary retention, erectile dysfunction, sudomotor failure, sicca symptoms, non-reactive pupils and severe orthostatic hypotension shortly after receiving the second dose of an mRNA vaccine against COVID19. Autonomic testing revealed severe cardiovagal, adrenergic and sudomotor impairment, and tonic 'half-mast' pupils with evidence of sympathetic and parasympathetic denervation. Pathological α3-ganglionic ACHR antibodies were positive in serum as detected by a new flow cytometric immunomodulation assay. Malignancy was excluded. The patient was diagnosed with severe, treatment-refractory acute AAG. CONCLUSIONS While autonomic dysfunction has been previously reported post-COVID19 vaccination, to our knowledge this is the first reported case of antibody-positive AAG in this setting. The severity of this case is in marked contrast to the existing literature on idiopathic antibody-positive autoimmune pandysautonomia.
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Affiliation(s)
- Simon Rowe
- Department of Neurology, Liverpool Hospital, Sydney, NSW, Australia,Corresponding author
| | - Judith M. Spies
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Nicolás Urriola
- Department of Clinical Immunology and Allergy, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Hayashi T, Nakane S, Mukaino A, Higuchi O, Yamakawa M, Matsuo H, Kimura K. Effectiveness of treatment for 31 patients with seropositive autoimmune autonomic ganglionopathy in Japan. Ther Adv Neurol Disord 2022; 15:17562864221110048. [PMID: 35966941 PMCID: PMC9364197 DOI: 10.1177/17562864221110048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 06/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background: Autoimmune autonomic ganglionopathy (AAG) is characterized by serum
autoantibodies against the ganglionic acetylcholine receptor (gAChR).
Immunomodulatory treatments may alleviate AAG symptoms, but the most
appropriate treatment strategy is unclear. Objective: This study aimed to confirm the effectiveness of treatments, particularly
immunotherapy, in patients with seropositive AAG in Japan, as well as to
determine the most effective treatment and the best assessment method for
clinical response to treatment. Methods: We collected data from a previous cohort study of patients with seropositive
AAG. The clinical autonomic and extra-autonomic symptoms were objectively
counted and subjectively assessed using the modified Composite Autonomic
Symptom Score. Post-treatment changes in the gAChR antibody level were
evaluated. Results: Thirty-one patients received immunotherapy. Among them, 19 patients received
intravenous methylprednisolone; 27, intravenous immunoglobulin; 3, plasma
exchange; 18, oral steroids; 2, tacrolimus; 1, cyclosporine; and 1,
mycophenolate mofetil. Patients who received immunotherapy showed
improvements in the total number of symptoms (from 6.2 ± 2.0 to 5.1 ± 2.0)
and modified Composite Autonomic Symptom Score (from 37.4 ± 15.3 to
26.6 ± 12.8). Orthostatic intolerance, sicca, and gastrointestinal symptoms
were ameliorated by immunotherapy. Immunotherapy decreased the antibody
levels (gAChRα3 antibodies, from 2.2 ± 0.4 to 1.9 ± 0.4,
p = 0.08; gAChRβ4 antibodies, from 1.6 ± 0.1 to 1.0 ± 0.2,
p = 0.002), but antibody levels increased in 10
patients despite immunotherapy. The rate of improvement in the total number
of symptoms was higher in patients with combined therapy than in patients
with non-combined therapy (70.7% vs 28.6%). Conclusions: The scores in many items on the rating scale decreased after immunotherapy in
patients with seropositive AAG, particularly in the combined immunotherapy
group. However, more accurate assessment scales for clinical symptoms and
multicenter randomized, placebo-controlled prospective studies are warranted
to establish future treatment strategies.
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Affiliation(s)
| | - Shunya Nakane
- Department of Neurology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo 113-8602, Japan
| | - Akihiro Mukaino
- Department of Japanese Oriental Medicine, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Osamu Higuchi
- Department of Clinical Research, NHO Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Makoto Yamakawa
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hidenori Matsuo
- Department of Neurology, NHO Nagasaki Hospital, Nagasaki, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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Postural tachycardia syndrome (POTS) and antiphospholipid syndrome (APS): What do we know so far? Rev Neurol (Paris) 2021; 178:306-314. [PMID: 34895744 DOI: 10.1016/j.neurol.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 11/21/2022]
Abstract
As part of the non-criteria clinical manifestations, postural orthostatic tachycardia syndrome (POTS), a multisystem autonomic dysfunction, can co-exist with antiphospholipid syndrome (APS). Several pieces of evidence hint on the autoimmune basis of POTS, and its possible association with several autoimmune diseases, including APS. Indeed, the evidence exists in the etiologies, symptomatology, and treatment options. Although infections, viral ones in particular, stress, and pregnancy are etiologies to both POTS and APS, the exact pathophysiological connection is still to be studied taking into consideration the activity of cytokines in both diseases. Nevertheless, certain immunomodulatory treatments used for the catastrophic or obstetrical forms of APS, such as intravenous immunoglobulins (IVIG) and steroids, have been also used for the treatment of POTS resistant to classical treatments. Therefore, our review aims to highlight the association between POTS and APS, shedding light on the common etiologies explaining the pathophysiology of the two disorders, the diagnostic approach to POTS as a possible clinical criterion of APS, and the treatment of APS in the context of treating POTS.
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12
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Murakami K, Koh J, Takahashi M, Ito H. [Acute-onset autoimmune autonomic ganglionopathy remarkably effective in intravenous high-dose immunoglobulin therapy]. Rinsho Shinkeigaku 2021; 61:687-691. [PMID: 34565756 DOI: 10.5692/clinicalneurol.cn-001631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
A 77-year-old woman developed acute onset of orthostatic hypotension, urinary retention, and constipation. Neurological examination on admission showed severe orthostatic hypotension accompanied by syncope, mydriatic pupils, and attenuation of light reflexes with no abnormalities in other neurological systems. Autonomic testing revealed denervation hypersensitivity in norepinephrine (NE) intravenous infusion test and 0.125% pilocarpine instillation test, low NE in the serum, and decreased amount of sweating in quantitative sudomotor axon reflex test. These findings indicated dysfunction of postganglionic autonomic nerves. Autoimmune autonomic ganglionopathy (AAG) was diagnosed due to the presence of anti-ganglionic acetylcholine receptors. The patient was given intravenous high-dose immunoglobulin therapy (IVIg), improving orthostatic hypotension, urinary retention, and constipation. Previous reports indicated that the response to IVIg varied from case to case. Thus, this case suggests that IVIg is effective in acute-onset AAG cases.
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Affiliation(s)
| | - Jinsoo Koh
- Department of Neurology, Wakayama Medical University
| | | | - Hidefumi Ito
- Department of Neurology, Wakayama Medical University
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13
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Goto Y, Sunami Y, Sugaya K, Nakane S, Takahashi K. [A case of chronic postural tachycardia syndrome with positive anti-ganglionic acetylcholine receptor (gAChR) antibody]. Rinsho Shinkeigaku 2021; 61:547-551. [PMID: 34275953 DOI: 10.5692/clinicalneurol.cn-001598] [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: 11/05/2022]
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a form of orthostatic intolerance characterized by symptoms such as lightheadedness, fainting, and brain fog that occur with a rapid elevation in heart rate when standing up from a reclining position. The etiology of POTS has yet to be established. However, a growing body of evidence suggests that POTS may be an autoimmune disorder such as autoimmune autonomic ganglionopathy, an acquired, immune-mediated form of diffuse autonomic failure. Many patients have serum antibodies that bind to the ganglionic acetylcholine receptors (gAChRs) in the autonomic ganglia. Herein, we describe a 39-year-old female patient with an eight-year history of orthostatic intolerance. POTS was diagnosed based on the findings of a head-up tilt test, in which a rapid increase in the patient's heart rate from 58 bpm in the lying position to 117 bpm in the upright position without orthostatic hypotension was observed. The POTS symptoms were refractory to various medications except for pyridostigmine bromide, which resulted in a partial resolution of her symptoms. Her serum was found to be strongly positive for anti-gAChR (β4 subunit) autoantibody (2.162 A.I., normal range: below 1.0). Based on these findings, a limited form of autoimmune POTS was diagnosed. After obtaining written informed consent, she was treated with intravenous immunoglobulin (IVIg) 400 mg/kg/day for five days, which led to clinical improvement by reducing her heart rate increase in the upright position. She was able to return to work with IVIg treatment at regular intervals. Our case provides further evidence of a potential autoimmune pathogenesis for POTS. Aggressive immunotherapy may be effective for POTS even in chronic cases.
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Affiliation(s)
- Yuya Goto
- Department of Neurology, Tokyo Metropolitan Neurological Hospital
| | - Yoko Sunami
- Department of Neurology, Tokyo Metropolitan Neurological Hospital
| | - Keizo Sugaya
- Department of Neurology, Tokyo Metropolitan Neurological Hospital
| | - Shunya Nakane
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital
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Clinical Features and Treatment Response in Immune-Mediated Small Fiber Neuropathy with Trisulfated Heparin Disaccharide or Fibroblast Growth Factor Receptor 3 Antibodies. J Clin Neuromuscul Dis 2021; 22:192-199. [PMID: 34019003 DOI: 10.1097/cnd.0000000000000355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Novel antibodies to trisulfated heparin disaccharide (TS-HDS) and fibroblast growth factor receptor 3 (FGFR-3) have been recently described in otherwise cryptogenic small fiber neuropathy (SFN) cases. Our goal was to further describe clinical features in such cases and to analyze treatment responses. METHODS In a retrospective analysis, 40 cases of cryptogenic SFN in a university neuropathy clinic were identified. Of these, TS-HDS and FGFR-3 cases were identified, and clinical features and treatment responses were analyzed. RESULTS In this cohort, 95% were women, and 55% had either TS-HDS or FGFR-3 antibodies (77% of these had TS-HDS). Of the seropositive group, 41% had a nonlength dependent epidermal nerve fiber density on skin punch biopsy (OR = 1.80). In the seropositive group, 82% had neuropathic pain as their primary symptom (OR = 1.73). Also 32% of seropositive patients reported widespread pain (OR = 1.63). 63% of seropositive cases presented acutely (OR = 11.0). In the seropositive group, 23% had an initial erroneous diagnosis (OR = 1.47). Eight seropositive patients improved on intravenous immunoglobulin treatment, with a 42% reduction in pain scores (P = 0.02), a 44% reduction in the Utah Neuropathy Score, and improved epidermal nerve fiber density post-treatment. CONCLUSIONS TS-HDS and FGFR-3 antibodies may be present in a high proportion of cryptogenic SFN cases with acute onset, nonlength dependent pathology, and primary neuropathic and widespread pain. They are often misdiagnosed as other conditions including fibromyalgia. These cases may be responsive to immune treatment, especially with intravenous immunoglobulin.
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15
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Koay S, Vichayanrat E, Bremner F, Panicker JN, Lang B, Lunn MP, Watson L, Ingle GT, Hagen EM, McNamara P, Jacobson L, Provitera V, Nolano M, Vincent A, Mathias CJ, Iodice V. Multimodal Biomarkers Quantify Recovery in Autoimmune Autonomic Ganglionopathy. Ann Neurol 2021; 89:753-768. [PMID: 33438240 DOI: 10.1002/ana.26018] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate patients with ganglionic acetylcholine receptor antibody (gAChR-Ab) positive autoimmune autonomic ganglionopathy using a multimodal testing protocol to characterize their full clinical phenotype and explore biomarkers to quantify immunotherapy response. METHODS We conducted a cohort study of 13 individuals (7 women, 21-69 years of age) with autonomic failure and gAChR-Ab >100 pM identified between 2005 and 2019. From 2018, all patients were longitudinally assessed with cardiovascular, pupillary, urinary, sudomotor, lacrimal and salivary testing, and Composite Autonomic Symptom Score (COMPASS-31) autonomic symptom questionnaires. The orthostatic intolerance ratio was calculated by dividing change in systolic blood pressure over time tolerated on head-up tilt. Eleven patients received immunotherapy. RESULTS At first assessment, all 13 patients had cardiovascular and pupillary impairments, 7 of 8 had postganglionic sudomotor dysfunction, 9 of 11 had urinary retention and xeropthalmia, and 6 of 8 had xerostomia. After immunotherapy, there were significant improvements in orthostatic intolerance ratio (33.3 [17.8-61.3] to 5.2 [1.4-8.2], p = 0.007), heart rate response to deep breathing (1.5 [0.0-3.3] to 4.5 [3.0-6.3], p = 0.02), pupillary constriction to light (12.0 [5.5-18.0] to 19.0 [10.6-23.8]%, p = 0.02), saliva production (0.01 [0.01-0.05] to 0.08 [0.02-0.20] g/min, p = 0.03), and COMPASS-31 scores (52 to 17, p = 0.03). Orthostatic intolerance ratio correlated with autonomic symptoms at baseline (r = 0.841, p = 0.01) and following immunotherapy (r = 0.889, p = 0.02). Immunofluorescence analyses of skin samples from a patient 32 years after disease onset showed loss of nerve fibers supplying the dermal autonomic adnexa and epidermis, with clear improvements following immunotherapy. INTERPRETATION Patients with autoimmune autonomic ganglionopathy demonstrated objective evidence of widespread sympathetic and parasympathetic autonomic failure, with significant improvements after immunotherapy. Quantitative autonomic biomarkers should be used to define initial deficits, guide therapeutic decisions, and document treatment response. ANN NEUROL 2021;89:753-768.
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Affiliation(s)
- Shiwen Koay
- Department of Brain, Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK.,Autonomic Unit, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Ekawat Vichayanrat
- Autonomic Unit, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Fion Bremner
- Department of Brain, Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK.,Neuro-Ophthalmology Department, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Jalesh N Panicker
- Department of Brain, Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK.,Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, Oxford University, John Radcliffe Hospital, Oxford, UK
| | - Michael P Lunn
- Neuroimmunology Unit, University College London Queen Square Institute of Neurology, London, UK.,MRC Centre for Neuromuscular Diseases, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Laura Watson
- Autonomic Unit, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Gordon T Ingle
- Autonomic Unit, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Ellen Merete Hagen
- Autonomic Unit, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Patricia McNamara
- Autonomic Unit, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Leslie Jacobson
- Nuffield Department of Clinical Neurosciences, Oxford University, John Radcliffe Hospital, Oxford, UK
| | - Vincenzo Provitera
- Neurology Department, Skin Biopsy Laboratory, Istituti Clinici Scientifici Maugeri IRCCS, Telese Terme, Italy.,Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II of Naples, Naples, Italy
| | - Maria Nolano
- Neurology Department, Skin Biopsy Laboratory, Istituti Clinici Scientifici Maugeri IRCCS, Telese Terme, Italy.,Department of Neurosciences, Reproductive Sciences and Odontostomatology, University Federico II of Naples, Naples, Italy
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, Oxford University, John Radcliffe Hospital, Oxford, UK.,Neurology Department, Skin Biopsy Laboratory, Istituti Clinici Scientifici Maugeri IRCCS, Telese Terme, Italy
| | - Christopher J Mathias
- Department of Brain, Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK.,Autonomic and Neurovascular Medicine Centre, Hospital of St. John and St. Elizabeth, London, UK
| | - Valeria Iodice
- Department of Brain, Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK.,Autonomic Unit, The National Hospital for Neurology and Neurosurgery, London, UK
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16
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Rodriguez B, Hoepner R, Salmen A, Kamber N, Z'Graggen WJ. Immunomodulatory treatment in postural tachycardia syndrome: A case series. Eur J Neurol 2021; 28:1692-1697. [PMID: 33382525 DOI: 10.1111/ene.14711] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Postural tachycardia syndrome (POTS) is a form of autonomic dysfunction characterized by symptoms of orthostatic intolerance, often accompanied by sudomotor dysfunction and gastrointestinal dysmotility. Recently, evidence has accumulated that in a subset of patients, the pathogenesis of dysautonomia may be immune-mediated. The aim of the current report was to evaluate the use of intravenous immunoglobulin (IVIG) treatment in patients with progressive and/or refractory immune-mediated POTS. METHODS We retroactively assessed the effect and tolerance of monthly administered IVIG in six patients using autonomic function testing, standardized symptom questionnaires, and patients' symptom diaries both before and 6 months into IVIG treatment. Objective outcome measures included heart rate increase after 10 min of head-up tilt as well as duration and anhidrotic area in a thermoregulatory sweat test. Subjective outcome measures were patient reports and symptom ratings from the symptom questionnaire. RESULTS All patients responded to immunomodulatory treatment, regardless of disease duration. After 6 months of IVIG, symptom severity was reduced by nearly 40%. Autonomic function testing showed improved cardiovascular functioning by 50% and a reduction of anhidrotic areas by one third. Overall, tolerance of IVIG treatment was poor, but could be improved by a reduction in infusion rate, premedication with steroids, and additional intravenous hydration. CONCLUSIONS Using subjective but also standardized objective measures, the case series describes promising effects of IVIG treatment in POTS patients with immune-mediated dysautonomia. By reducing the infusion rate, pretreatment with steroids, and intravenous hydration, tolerance could be improved, and no patient had to discontinue the treatment.
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Affiliation(s)
- Belén Rodriguez
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Anke Salmen
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Nicole Kamber
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland.,Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
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17
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Kaur D, Tiwana H, Stino A, Sandroni P. Autonomic neuropathies. Muscle Nerve 2020; 63:10-21. [PMID: 32926436 DOI: 10.1002/mus.27048] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 12/17/2022]
Abstract
Autonomic neuropathies represent a complex group of disorders that preferentially target autonomic fibers and can be classified as either acute/subacute or chronic in onset. Acute-onset autonomic neuropathies manifest with such conditions as paraneoplastic syndromes, Guillain-Barre syndrome, Sjögren syndrome, infection, or toxins/chemotherapy. When the presentation is acute, immune-mediated, and without a secondary cause, autoimmune autonomic ganglionopathy is likely, and should be considered for immunotherapy. Of the chronic-onset forms, diabetes is the most widespread and disabling, with autonomic impairment portending increased mortality and cardiac wall remodeling risk. Acquired light chain (AL) and transthyretin (TTR) amyloidosis represent two other key etiologies, with TTR amyloidosis now amenable to newly-approved gene-modifying therapies. The COMPASS-31 questionnaire is a validated outcome measure that can be used to monitor autonomic severity and track treatment response. Symptomatic treatments targeting orthostatic hypotension, among other symptoms, should be individualized and complement disease-modifying therapy, when possible.
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Affiliation(s)
- Divpreet Kaur
- Department of Neurology, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Harmanpreet Tiwana
- Department of Neurology, Dartmouth-Hitchcok Medical Center, Lebanon, New Hampshire, USA
| | - Amro Stino
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Paola Sandroni
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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18
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Nakane S, Mukaino A, Ihara E, Ogawa Y. Autoimmune gastrointestinal dysmotility: the interface between clinical immunology and neurogastroenterology. Immunol Med 2020; 44:74-85. [DOI: 10.1080/25785826.2020.1797319] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Shunya Nakane
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan
| | - Akihiro Mukaino
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan
| | - Eikichi Ihara
- Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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19
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Abstract
PURPOSE OF REVIEW Autonomic disorders sometimes occur in the context of systemic autoimmune disease or as a direct consequence of autoimmunity against the nervous system. This article provides an overview of autonomic disorders with potential autoimmune etiology. RECENT FINDINGS Recent evidence highlights a close association between the autonomic nervous system and inflammation. The autonomic nervous system regulates immune function, and autonomic manifestations may occur in a number of systemic autoimmune diseases. In a few instances, autoimmunity directly influences autonomic function. Autoimmune autonomic ganglionopathy is the prototypic antibody-mediated autonomic disorder. Over time, a better understanding of the clinical spectrum of autoimmune autonomic ganglionopathy, the significance of ganglionic nicotinic acetylcholine receptor antibodies, other immune-mediated autonomic neuropathies, and autonomic manifestations of other systemic or neurologic autoimmune disorders has emerged. SUMMARY Autoimmune autonomic disorders may be challenging, but correct identification of these conditions is important. In some cases, potential exists for effective immunomodulatory treatment.
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20
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Nakane S. [Autoimmune autonomic ganglionopathy]. Rinsho Shinkeigaku 2019; 59:783-790. [PMID: 31761837 DOI: 10.5692/clinicalneurol.cn-001354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder of widespread autonomic failure. Approximately half of the patients with AAG have the autoantibodies against the neuronal nicotinic acetylcholine receptor (AChR) in autonomic ganglia. These ganglionic AChR antibodies have the potential to mediate the synaptic transmission in sympathetic, parasympathetic, and enteric ganglia. Therefore, seropositive AAG patients exhibit various autonomic symptoms. Extra-autonomic manifestations (coexistence with brain involvement, sensory disturbance, endocrine disorders, autoimmune diseases and tumors) are present in many patients with AAG. The nicotinic AChRs comprise a family of abundantly expressed ligand-gated cation channels found throughout the central and peripheral nervous systems. Moreover, limited manifestations of autoimmune dysautonomia including autoimmune gastrointestinal dysmotility are newly recognized clinical entity. Although combined immunomodulatory therapy is beneficial for almost all patients with AAG, several case reports of some AAG patients with small benefit exist. This review focuses on the recent progress in the clinical approaches of AAG and its related disorders involving the role of autoantibodies and clinical practice.
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Affiliation(s)
- Shunya Nakane
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital
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21
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Gao CA, Weber UM, Peixoto AJ, Weiss SA. Seronegative autoimmune autonomic ganglionopathy from dual immune checkpoint inhibition in a patient with metastatic melanoma. J Immunother Cancer 2019; 7:262. [PMID: 31623673 PMCID: PMC6796437 DOI: 10.1186/s40425-019-0748-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/20/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors have improved clinical outcomes including survival in several malignancies but have also been associated with a range of immune-related adverse events (irAEs). Neurological irAEs are rare compared to the more typical skin, gastrointestinal, and endocrine toxicities, and are often underrecognized and challenging to diagnose. Here, we report a case of seronegative autoimmune autonomic ganglionopathy (AAG) induced by dual immune checkpoint inhibitor therapy (ICI) in a patient with metastatic melanoma. CASE PRESENTATION A patient with metastatic melanoma was treated with ipilimumab and nivolumab. He developed a constellation of new symptoms including nausea, fatigue, and severe orthostatic hypotension refractory to fluid resuscitation. An infectious, cardiac, neurologic, and endocrine workup were unrevealing. Cardiovascular autonomic testing revealed poor sympathetic nervous system responses. He was diagnosed with seronegative AAG and significantly improved with immunomodulatory therapies including IVIG and steroids as well as varying doses of midodrine and fludrocortisone. He was able to restart nivolumab without recurrence of his symptoms. However, the AAG reoccurred when he was re-challenged with ipilimumab and nivolumab due to disease progression. While the AAG was manageable with steroids at that time, unfortunately his melanoma became resistant to ICI. CONCLUSIONS Immune checkpoint inhibitors can have a wide range of unusual, rare irAEs, including neurotoxicity such as AAG. Clinicians should maintain suspicion for this toxicity so that treatment can be rapidly provided to avoid disability.
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Affiliation(s)
- Catherine A Gao
- Department of Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Urs M Weber
- Department of Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Aldo J Peixoto
- Department of Medicine (Nephrology), Yale University School of Medicine, 330 Cedar Street, Boardman 114, New Haven, CT, 06520, USA
| | - Sarah A Weiss
- Department of Medicine (Medical Oncology), Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA.
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22
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Intravenous Immunoglobulin Therapy in Refractory Autoimmune Dysautonomias: A Retrospective Analysis of 38 Patients. Am J Ther 2019; 26:570-582. [DOI: 10.1097/mjt.0000000000000778] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Golden EP, Vernino S. Autoimmune autonomic neuropathies and ganglionopathies: epidemiology, pathophysiology, and therapeutic advances. Clin Auton Res 2019; 29:277-288. [DOI: 10.1007/s10286-019-00611-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/03/2019] [Indexed: 12/12/2022]
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24
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Abstract
Autonomic complaints are frequently encountered in clinical practice. They can be due to primary autonomic disorders or secondary to other medical conditions. Primary autonomic disorders can be categorized as orthostatic intolerance syndromes and small fiber neuropathies; the latter are associated with autonomic failure, pain, or their combinations. The review outlines orthostatic intolerance syndromes (neurally mediated syncope, orthostatic hypotension, postural tachycardia syndrome, inappropriate sinus tachycardia, orthostatic cerebral hypoperfusion syndrome, and hypocapnic cerebral hypoperfusion) and small fiber neuropathies (sensory/autonomic/mixed, acute/subacute/chronic, idiopathic/secondary, inflammatory and noninflammatory). Several specific autonomic syndromes (diabetic neuropathy, primary hyperhidrosis, paroxysmal sympathetic hyperactivity, autonomic dysreflexia), neurogenic bladder, and gastrointestinal motility disorders are discussed as well.
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25
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Bouxin M, Schvartz B, Mestrallet S, Debrumetz A, Hentzien M, Tabary T, Cohen R, Nicolas G, Bani-Sadr F. Rituximab treatment in seronegative autoimmune autonomic neuropathy and autoimmune autonomic ganglionopathy: Case-report and literature review. J Neuroimmunol 2018; 326:28-32. [PMID: 30468952 DOI: 10.1016/j.jneuroim.2018.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/13/2018] [Accepted: 11/13/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Autoimmune autonomic ganglionopathy (AAG) is a rare disease with no well-established treatment. Until recently, AAG could be seropositive (50 to 60% of patients) or seronegative for ganglionic (α3-type) nicotinic acetylcholine receptor (Gα3NAChR) antibodies. In early 2018, the two forms of the disease were distinguished, separating seropositive from seronegative ones, designating this latter form "seronegative autoimmune autonomic neuropathy" (SAAN). Most described treatments are plasma exchange (PE) and intravenous immunoglobulin (IVIG). However in some cases with no or small benefit, other immunomodulatory therapies, such as rituximab have been reported. We report the case of a 24-year-old female patient successfully treated for SAAN with rituximab and steroids after IVIG and PE failure. We also provide a review of case-reports reporting rituximab treatment for both SAAN and AAG. METHODS To identify articles reporting SAAN and AAG treatment with rituximab, we searched the PubMed database using the terms "autoimmune autonomic ganglionopathy", "autoimmune autonomic neuropathy" or "seronegative autoimmune autonomic neuropathy" and "rituximab". RESULTS Including our patient, nine cases have been described in the literature (4 SAAN and 5 AAG). Rituximab had a significant positive effect in 2 out of 4 SAAN and all 5 AAG cases, used alone or in association with other etiologic treatments. CONCLUSION Our study suggests rituximab (alone or in association with other treatments) could provide efficacy in both SAAN and AAG when PE and/or IVIG are not effective enough.
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Affiliation(s)
- M Bouxin
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - B Schvartz
- Department of Nephrology and Transplantation, Reims Teaching Hospitals, Reims, France
| | - S Mestrallet
- Department of Internal Medicine and Infectious Diseases, CH de Charleville-Mézières, Charleville-Mézières, France
| | - A Debrumetz
- Department of Nephrology and Transplantation, Reims Teaching Hospitals, Reims, France
| | - M Hentzien
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - T Tabary
- Immunology Laboratory, Reims Teaching Hospitals, Reims, France
| | - R Cohen
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - G Nicolas
- Department of Neurology, Assistance Publique des Hôpitaux de Paris, Raymond-Poincaré Hospital, Garches, France
| | - F Bani-Sadr
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France; University of Reims Champagne-Ardenne, EA-4684 / SFR CAP-SANTE, Reims F-51095, France.
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Nakane S, Mukaino A, Higuchi O, Watari M, Maeda Y, Yamakawa M, Nakahara K, Takamatsu K, Matsuo H, Ando Y. Autoimmune autonomic ganglionopathy: an update on diagnosis and treatment. Expert Rev Neurother 2018; 18:953-965. [PMID: 30352532 DOI: 10.1080/14737175.2018.1540304] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder that leads to autonomic failure. The disorder is associated with autoantibodies to the ganglionic nicotinic acetylcholine receptor (gAChR). We subsequently reported that AAG is associated with an overrepresentation of psychiatric symptoms, sensory disturbance, autoimmune diseases, and endocrine disorders. Area covered: The aim of this review was to describe AAG and highlight its pivotal pathophysiological aspects, clinical features, laboratory examinations, and therapeutic options. Expert commentary: AAG is a complex neuroimmunological disease, these days considered as an autonomic failure with extra-autonomic manifestations (and various limited forms). Further comprehension of the pathophysiology of this disease is required, especially the mechanisms of the extra-autonomic manifestations should be elucidated. There is the possibility that the co-presence of antibodies that were directed against the other subunits in both the central and peripheral nAChRs in the serum of the AAG patients. Some patients improve with immunotherapies such as IVIg and/or corticosteroid and/or plasma exchange. 123I-MIBG myocardial scintigraphy may be a useful tool to monitor the therapeutic effects of immunotherapies.
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Affiliation(s)
- Shunya Nakane
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan.,b Department of Molecular Neurology and Therapeutics , Kumamoto University Hospital , Kumamoto , Japan
| | - Akihiro Mukaino
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan.,b Department of Molecular Neurology and Therapeutics , Kumamoto University Hospital , Kumamoto , Japan
| | - Osamu Higuchi
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Mari Watari
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Yasuhiro Maeda
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Makoto Yamakawa
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Keiichi Nakahara
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Koutaro Takamatsu
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Hidenori Matsuo
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Yukio Ando
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
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27
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Ketterer B, Montanaro A, Hunter AJ. So Much More than Bald and Bloated. J Hosp Med 2018; 13:863-867. [PMID: 30255858 DOI: 10.12788/jhm.3083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Briana Ketterer
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Anthony Montanaro
- Division of Allergy and Immunology, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Alan J Hunter
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Cutsforth-Gregory JK, McKeon A, Coon EA, Sletten DM, Suarez M, Sandroni P, Singer W, Benarroch EE, Fealey RD, Low PA. Ganglionic Antibody Level as a Predictor of Severity of Autonomic Failure. Mayo Clin Proc 2018; 93:1440-1447. [PMID: 30170741 PMCID: PMC6173625 DOI: 10.1016/j.mayocp.2018.05.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/30/2018] [Accepted: 05/07/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess antibody level as a test of autonomic failure (AF) associated with ganglionic nicotinic acetylcholine receptor antibody (AChR-Ab) autoimmunity. PATIENTS AND METHODS We searched the Mayo Clinic laboratory database of 926 ganglionic AChR-Ab-seropositive patients seen at our institution between October 1, 1997, and April 1, 2015, for initial level of 0.05 nmol/L or higher and contemporaneous autonomic reflex screen (standardized evaluation of adrenergic, cardiovagal, and sudomotor functions) from which Composite Autonomic Scoring Scale (CASS) scores could be calculated. RESULTS Of 289 patients who met inclusion criteria, 163 (56.4%) were women, median age was 54 years (range, 10-87 years), median antibody level was 0.11 nmol/L (range, 0.05-22.10 nmol/L), and median CASS total score was 2.0 (range, 0-10). Using receiver operating characteristic curve analysis, a level above 0.40 nmol/L predicted severe AF (CASS score, ≥7) with 92% specificity and 56% sensitivity. For at least moderate AF (CASS score ≥4 and anhidrosis ≥25%), a level of at least 0.20 nmol/L had 80% specificity and 59% sensitivity. Levels below 0.20 nmol/L were not predictive of the presence or absence of AF. For predicting orthostatic hypotension, ganglionic AChR-Ab level had excellent specificity above 0.4 nmol/L but lacked sensitivity. Autoantibodies to additional targets were present in 61 patients (21.1%). CONCLUSION Ganglionic AChR-Ab level of at least 0.40 nmol/L is a moderately sensitive and highly specific marker for severe AF, as is a level of at least 0.20 nmol/L for moderate AF if CASS score is coupled with anhidrosis of 25% or more, among patients with suspected ganglionic AChR-Ab autoimmune autonomic ganglionopathy. Antibody levels of less than 0.20 nmol/L have little clinical importance in the absence of clinical AF.
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Affiliation(s)
| | - Andrew McKeon
- Department of Neurology, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | | | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN.
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Palma JA, Norcliffe-Kaufmann L, Martinez J, Kaufmann H. Supine plasma NE predicts the pressor response to droxidopa in neurogenic orthostatic hypotension. Neurology 2018; 91:e1539-e1544. [PMID: 30232253 DOI: 10.1212/wnl.0000000000006369] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/12/2018] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To test whether the plasma levels of norepinephrine (NE) in patients with neurogenic orthostatic hypotension (nOH) predict their pressor response to droxidopa. METHODS This was an observational study, which included patients with nOH. All patients had standardized autonomic function testing including determination of venous plasma catecholamine levels drawn through an indwelling catheter while resting supine. This was followed by a droxidopa titration with 100 mg increments in successive days until relief of symptoms, side effects, or the maximum dose of 600 mg was reached. No response was defined as an increase of <10 mm Hg in systolic blood pressure (BP) after 3-minute standing 1 hour after droxidopa administration. Nonlinear regression models were used to determine the relationship between BP response and plasma NE levels. RESULTS We studied 20 patients with nOH due to Parkinson disease, pure autonomic failure, multiple system atrophy, or autoimmune autonomic neuropathies. Their supine plasma NE levels ranged from 44 to 850 pg/mL. Lower supine plasma NE levels were associated with greater pressor effect 1 hour after dose (R2 = 0.49) and higher standing BP (R2 = 0.45). Patients with no pressor response to droxidopa had higher NE levels (382 ± 100 vs 115 ± 20 pg/mL, p = 0.0014). A supine NE level of <219.5 pg/mL had 83% sensitivity and 93% specificity to predict a pressor response (area under the curve = 0.95, p = 0.0023). CONCLUSIONS In patients with nOH, lower supine resting plasma NE levels are associated with a greater pressor effect of droxidopa treatment. This finding should help identify patients with nOH most likely to respond to standard doses of droxidopa. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that lower supine plasma NE levels accurately identify patients with nOH more likely to have a greater pressor effect from droxidopa.
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Affiliation(s)
- Jose-Alberto Palma
- From the Department of Neurology, Dysautonomia Center, New York University School of Medicine
| | - Lucy Norcliffe-Kaufmann
- From the Department of Neurology, Dysautonomia Center, New York University School of Medicine
| | - Jose Martinez
- From the Department of Neurology, Dysautonomia Center, New York University School of Medicine
| | - Horacio Kaufmann
- From the Department of Neurology, Dysautonomia Center, New York University School of Medicine.
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Zadourian A, Doherty TA, Swiatkiewicz I, Taub PR. Postural Orthostatic Tachycardia Syndrome: Prevalence, Pathophysiology, and Management. Drugs 2018; 78:983-994. [DOI: 10.1007/s40265-018-0931-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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31
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Seronegative and seropositive autoimmune autonomic ganglionopathy (AAG): Same clinical picture, same response to immunotherapy. J Neuroimmunol 2018; 319:68-70. [PMID: 29685292 DOI: 10.1016/j.jneuroim.2018.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 03/24/2018] [Accepted: 03/28/2018] [Indexed: 11/21/2022]
Abstract
Two patients with a syndrome of pandisautonomia with clinical criteria of AAG are provided. Both patients present a similar clinical picture and response to immunosuppressive treatment. One of them has positive antibodies against the ganglionic nicotinic acetylcholine (gAChr) and the other does not. This brief article serves to reflect the spectrum of AAG, at a clinical level, in laboratory tests and in the response to immunotherapy, independently of the presence of positive gAChr antibodies.
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32
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Ashat M, Lewis A, Liaquat H, Stocker A, McElmurray L, Vedanarayanan V, Soota K, Howell T, Kedar A, Obert J, Abell TL. Intravenous immunoglobulin in drug and device refractory patients with the symptoms of gastroparesis-an open-label study. Neurogastroenterol Motil 2018; 30. [PMID: 29205691 DOI: 10.1111/nmo.13256] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 10/29/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastroparesis is a complex clinical entity; many aspects of which remain unknown. Although most patients have idiopathic, diabetic, or postsurgical gastroparesis, many are thought to have measurable neuromuscular abnormalities. Immunotherapy has recently been utilized to treat suspected autoimmune gastrointestinal dysmotility. METHODS Fourteen patients with symptoms of gastroparesis (Gp) who were refractory to drug/device were selected from 443 Gp patients from 2013 to 2015 who were treated at the University of Louisville motility center. All patients underwent a structural and psychiatric evaluation along with detailed psychological and behavioral examination to rule out eating disorders. We performed detailed neuromuscular evaluation and all 14 patients received at least 12 weeks of intravenous immunoglobulin (400 mg/kg infusion weekly). Response was defined subjectively (symptomatic improvement) using standardized IDIOM score system. KEY RESULTS All 14 patients had serological evidence and/or tissue evidence of immunological abnormality. Post-IVIG therapy, there was a significant improvement in symptoms scores for nausea, vomiting, early satiety, and abdominal pain. CONCLUSIONS AND INFERENCES Although limited by the absence of placebo group, the data illustrate the role of autoimmunity and neuromuscular evaluation in patients with gastroparesis and support the utility of a diagnostic trial of immunotherapy in an effort to improve therapeutic outcomes for such patients.
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Affiliation(s)
- M Ashat
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - A Lewis
- Department of Internal Medicine, University of Louisville, Louisville, KY, USA
| | - H Liaquat
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - A Stocker
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - L McElmurray
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - V Vedanarayanan
- Division of Neuromuscular Medicine, University of Mississippi, Oxford, MS, USA
| | - K Soota
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - T Howell
- GI Motility Clinic, Jewish Hospital, Louisville, KY, USA
| | - A Kedar
- Division of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - J Obert
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - T L Abell
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, Jewish Hospital GI Motility Clinic, University of Louisville, Louisville, KY, USA
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Wells R, Spurrier AJ, Linz D, Gallagher C, Mahajan R, Sanders P, Page A, Lau DH. Postural tachycardia syndrome: current perspectives. Vasc Health Risk Manag 2017; 14:1-11. [PMID: 29343965 PMCID: PMC5749569 DOI: 10.2147/vhrm.s127393] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Postural tachycardia syndrome (POTS) is the combination of an exaggerated heart rate response to standing, in association with symptoms of lightheadedness or pre-syncope that improve when recumbent. The condition is often associated with fatigue and brain fog, resulting in significant disruptions at a critical time of diagnosis in adolescence and young adulthood. The heterogeneity of the underlying pathophysiology and the variable response to therapeutic interventions make management of this condition challenging for both patients and physicians alike. Here, we aim to review the factors and mechanisms that may contribute to the symptoms and signs of POTS and to present our perspectives on the clinical approach toward the diagnosis and management of this complex syndrome.
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Affiliation(s)
- Rachel Wells
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Departments of Cardiology and Medicine, Royal Adelaide Hospital.,Department of Medicine, Royal Adelaide Hospital
| | | | - Dominik Linz
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Departments of Cardiology and Medicine, Royal Adelaide Hospital
| | - Celine Gallagher
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Departments of Cardiology and Medicine, Royal Adelaide Hospital
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Departments of Cardiology and Medicine, Royal Adelaide Hospital
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Departments of Cardiology and Medicine, Royal Adelaide Hospital
| | - Amanda Page
- Centre for Nutrition and Gastrointestinal Diseases, University of Adelaide, Adelaide, SA, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Departments of Cardiology and Medicine, Royal Adelaide Hospital
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34
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Seronegative autoimmune autonomic neuropathy: a distinct clinical entity. Clin Auton Res 2017; 28:115-123. [DOI: 10.1007/s10286-017-0493-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/16/2017] [Indexed: 10/18/2022]
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Nakae Y, Hyuga M, Terada Y, Kishimoto W, Fukunaga A, Tabata S, Maesako Y, Komatsu K, Higuchi O, Nakane T, Arima N. Multiple Myeloma Presenting with Autoimmune Autonomic Ganglionopathy. Intern Med 2017; 56:3347-3351. [PMID: 29021436 PMCID: PMC5790725 DOI: 10.2169/internalmedicine.9096-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Autoimmune autonomic ganglionopathy is an autonomic disorder that occurs as a symptom of paraneoplastic neurological syndrome. To date, there have been no reports on multiple myeloma with autoimmune autonomic ganglionopathy. A 37-year-old Japanese woman suffered from orthostatic hypotension was diagnosed with multiple myeloma (IgG kappa type), and a serological examination revealed the presence of anti-ganglionic nicotinic acetylcholine receptor (anti-gAChR) antibodies. She was treated for multiple myeloma, as a result, the autonomic disturbance improved and her anti-gAChR antibody titer decreased to undetectable levels, despite the fact that she only achieved a partial remission of multiple myeloma. Treatment for multiple myeloma may improve autoimmune autonomic ganglionopathy.
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Affiliation(s)
- Yoshiki Nakae
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Mizuki Hyuga
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Yuta Terada
- Department of Neurology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Wataru Kishimoto
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Akiko Fukunaga
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Sumie Tabata
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Yoshitomo Maesako
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Kenichi Komatsu
- Department of Neurology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Osamu Higuchi
- Department of Clinical Research, National Hospital Organization Nagasaki Kawatana Medical Center, Japan
| | | | - Nobuyoshi Arima
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
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36
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Wells R, Tonkin A. Clinical approach to autonomic dysfunction. Intern Med J 2017; 46:1134-1139. [PMID: 27734621 DOI: 10.1111/imj.13216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/17/2016] [Accepted: 03/24/2016] [Indexed: 12/20/2022]
Abstract
Patients with autonomic dysfunction may present with a variety of seemingly unrelated symptoms, both generalised and involving specific systems, including fatigue, difficulty concentrating, orthostatic intolerance, palpitations, constipation or diarrhoea, early satiety, urinary retention or incontinence and erectile dysfunction. Failure to connect the diverse symptoms with a single underlying mechanism may lead to incorrect diagnoses, inappropriate interventions and frustration on the part of both doctors and patients. We describe recent developments in the understanding of the pathophysiology of autonomic dysfunction, including the link between the autonomic and immune systems resulting in the 'inflammatory reflex'. We then provide a rationale to guide the management of patients exhibiting features of autonomic dysfunction, including postural tachycardia syndrome.
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Affiliation(s)
- R Wells
- Department of Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| | - A Tonkin
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Schmitt M, Samson M, Leguy-Seguin V, Robert R, Berthier S, Nicolas B, Guilhem A, Jacquin A, Lakomy D, Cottin Y, Audia S, Bonnotte B. Une cause rare de syndrome dysautonomique. Rev Med Interne 2016. [DOI: 10.1016/j.revmed.2016.10.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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38
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Kleyman I, Weimer LH. Syncope: Case Studies. Neurol Clin 2016; 34:525-45. [PMID: 27445240 DOI: 10.1016/j.ncl.2016.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Syncope, or the sudden loss of consciousness, is a common presenting symptom for evaluation by neurologists. It is not a unique diagnosis but rather a common manifestation of disorders with diverse mechanisms. Loss of consciousness is typically preceded by a prodrome of symptoms and sometimes there is a clear trigger. This article discusses several cases that illustrate the various causes of syncope. Reflex syncope is the most common type and includes neurally mediated, vasovagal, situational, carotid sinus hypersensitivity, and atypical forms. Acute and chronic autonomic neuropathies and neurodegenerative disorders can also present with syncope.
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Affiliation(s)
- Inna Kleyman
- Department of Neurology, Columbia University College of Physicians and Surgeons, Neurological Institute of New York, 710 West 168th Street, New York, NY 10032, USA
| | - Louis H Weimer
- Department of Neurology, Columbia University College of Physicians and Surgeons, Neurological Institute of New York, 710 West 168th Street, New York, NY 10032, USA.
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39
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Kuki I, Kawawaki H, Okazaki S, Hattori Y, Horino A, Higuchi O, Nakane S. Autoimmune autonomic ganglionopathy in a pediatric patient presenting with acute encephalitis. Brain Dev 2016; 38:605-8. [PMID: 26740077 DOI: 10.1016/j.braindev.2015.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 12/16/2015] [Accepted: 12/18/2015] [Indexed: 11/26/2022]
Abstract
Autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder that leads to systemic autonomic failure. Autoantibodies to the ganglionic nicotinic acetylcholine receptor (gAChR) are detected in 50% of AAG patients. We report the first pediatric case of AAG presenting with acute encephalitis. The patient was a 13-year-old boy who presented with orthostatic hypotension, followed by rapidly progressing disturbance of consciousness. Cerebrospinal fluid analysis revealed significant pleocytosis and increased neopterin concentration. Head MRI showed hyperintensities in bilateral caudate nuclei, putamen, hippocampus, and insula cortex. Severe autonomic dysfunctions such as severe orthostatic hypotension, bradycardia, dysuria, prolonged constipation and vomiting appeared. These symptoms were successfully controlled by repeated immunomodulating therapy with intravenous methylprednisolone pulse therapy and intravenous immunoglobulin. Autoantibodies to the α3 subunit of gAChR were detected at neurological onset, but were undetectable five months later. This observation indicates that AAG should be suspected in patients manifesting acute encephalitis characterized by preceding and prolonged autonomic symptoms, and immunomodulating therapy from an early stage can be effective.
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Affiliation(s)
- Ichiro Kuki
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan.
| | - Hisashi Kawawaki
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Shin Okazaki
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Yuka Hattori
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Asako Horino
- Department of Pediatric Neurology, Osaka City General Hospital, Osaka, Japan
| | - Osamu Higuchi
- Department of Clinical Research, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Shunya Nakane
- Department of Clinical Research, Nagasaki Kawatana Medical Center, Nagasaki, Japan
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Abstract
Peripheral neuropathies have diverse acquired and inherited causes. The autoimmune neuropathies represent an important category where treatment is often available. There are overlapping signs and symptoms between autoimmune neuropathies and other forms. Making a diagnosis can be challenging and first assisted by electrophysiologic and sometimes pathologic sampling, with autoimmune biomarkers providing increased assistance. Here we provide a review of the autoimmune and inflammatory neuropathies, their available biomarkers, and approaches to treatment. Also discussed is new evidence to support a mechanism of autoimmune pain.
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41
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Rituximab-based therapy and long-term control of autoimmune autonomic ganglionopathy. Clin Auton Res 2015; 25:255-8. [DOI: 10.1007/s10286-015-0299-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 05/12/2015] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW This article focuses on the most prevalent forms of autonomic neuropathies, but also discusses conditions such as focal and dysfunctional syndromes (altered autonomic function in the absence of structural lesions). The goal of this review is to allow the reader to promptly recognize these disorders, identify potentially reversible or treatable causes, and implement the appropriate treatment as well as supportive care. RECENT FINDINGS Secondary forms of autonomic neuropathies (eg, diabetes mellitus, amyloidosis) are much more common than primary forms, of which autoimmune ganglioneuropathies represent a major component. However, the spectrum of the latter is continuously evolving and has diagnostic and therapeutic implications. Testing modalities such as autonomic testing, serum autoimmune antibody testing, and skin biopsies are becoming more widely available. SUMMARY Autonomic neuropathies are relatively common conditions, and, because of the prognostic implications as well as impact on patient quality of life, they should be promptly recognized and treated aggressively. Testing is critical as other conditions may mimic autonomic neuropathies. Treatment is symptomatic in many cases, but specific therapies are also available in selected autonomic neuropathies.
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Tork S, Kelley SR, Tymitz KM. A Novel Use of N-Acetylcystine for the Management of Recurrent Small Bowel Pseudo-Obstruction in a Patient with Autoimmune Autonomic Ganglionopathy. Am Surg 2015. [DOI: 10.1177/000313481508100515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shahryar Tork
- Department of Surgery, Good Samaritan Hospital, Cincinnati, Ohio
| | - Scott R. Kelley
- Department of Surgery, Good Samaritan Hospital, Cincinnati, Ohio
| | - Kevin M. Tymitz
- Department of Surgery, Good Samaritan Hospital, Cincinnati, Ohio
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Nakane S, Higuchi O, Koga M, Kanda T, Murata K, Suzuki T, Kurono H, Kunimoto M, Kaida KI, Mukaino A, Sakai W, Maeda Y, Matsuo H. Clinical features of autoimmune autonomic ganglionopathy and the detection of subunit-specific autoantibodies to the ganglionic acetylcholine receptor in Japanese patients. PLoS One 2015; 10:e0118312. [PMID: 25790156 PMCID: PMC4366081 DOI: 10.1371/journal.pone.0118312] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 01/14/2015] [Indexed: 01/08/2023] Open
Abstract
Autoimmune autonomic ganglionopathy (AAG) is a rare acquired channelopathy that is characterized by pandysautonomia, in which autoantibodies to ganglionic nicotinic acetylcholine receptors (gAChR) may play a central role. Radioimmunoprecipitation (RIP) assays have been used for the sensitive detection of autoantibodies to gAChR in the serum of patients with AAG. Here, we developed luciferase immunoprecipitation systems (LIPS) to diagnose AAG based on IgGs to both the α3 and β4 gAChR subunits in patient serum. We reviewed the serological and clinical data of 50 Japanese patients who were diagnosed with AAG. With the LIPS testing, we detected anti-α3 and -β4 gAChR antibodies in 48% (24/50) of the patients. A gradual mode of onset was more common in the seropositive group than in the seronegative group. Patients with AAG frequently have orthostatic hypotension and upper and lower gastrointestinal tract symptoms, with or without anti-gAChR. The occurrence of autonomic symptoms was not significantly different between the seropositive and seronegative group, with the exception of achalasia in three patients from the seropositive group. In addition, we found a significant overrepresentation of autoimmune diseases in the seropositive group and endocrinological abnormalities as an occasional complication of AAG. Our results demonstrated that the LIPS assay was a useful novel tool for detecting autoantibodies against gAChR in patients with AAG.
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Affiliation(s)
- Shunya Nakane
- Department of Clinical Research, Nagasaki Kawatana Medical Center, Nagasaki, Japan; Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Osamu Higuchi
- Department of Clinical Research, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Kenya Murata
- Department of Neurology, Wakayama Medical University, Wakayama, Japan
| | - Takashi Suzuki
- Department of Neurology, Joetsu General Hospital, Niigata, Japan
| | - Hiroko Kurono
- Department of Neurology, Saiseikai Kanagawa Prefecture Hospital, Kanagawa, Japan
| | - Masanari Kunimoto
- Department of Neurology, Saiseikai Kanagawa Prefecture Hospital, Kanagawa, Japan
| | - Ken-ichi Kaida
- Division of Neurology, Department of Internal Medicine 3, National Defense Medical College, Saitama, Japan
| | - Akihiro Mukaino
- Department of Clinical Neuroscience and Neurology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Waka Sakai
- Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Yasuhiro Maeda
- Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Hidenori Matsuo
- Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
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Nishihara H, Koga M, Higuchi O, Tasaki A, Ogasawara JI, Kawai M, Nakane S, Kanda T. Combined immunomodulatory therapies resulted in stepwise recovery in autoimmune autonomic ganglionopathy. ACTA ACUST UNITED AC 2014. [DOI: 10.1111/cen3.12137] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hideaki Nishihara
- Department of Neurology and Clinical Neuroscience; Graduate School of Medicine; Yamaguchi University; Yamaguchi Japan
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience; Graduate School of Medicine; Yamaguchi University; Yamaguchi Japan
| | - Osamu Higuchi
- Department of Clinical Research; Nagasaki Kawatana Medical Center; Nagasaki Japan
| | - Ayako Tasaki
- Department of Neurology and Clinical Neuroscience; Graduate School of Medicine; Yamaguchi University; Yamaguchi Japan
| | - Jun-ichi Ogasawara
- Department of Neurology and Clinical Neuroscience; Graduate School of Medicine; Yamaguchi University; Yamaguchi Japan
| | - Motoharu Kawai
- Department of Neurology and Clinical Neuroscience; Graduate School of Medicine; Yamaguchi University; Yamaguchi Japan
| | - Shunya Nakane
- Department of Clinical Research; Nagasaki Kawatana Medical Center; Nagasaki Japan
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience; Graduate School of Medicine; Yamaguchi University; Yamaguchi Japan
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46
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Benarroch EE. The clinical approach to autonomic failure in neurological disorders. Nat Rev Neurol 2014; 10:396-407. [DOI: 10.1038/nrneurol.2014.88] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Schofield JR, Blitshteyn S, Shoenfeld Y, Hughes GRV. Postural tachycardia syndrome (POTS) and other autonomic disorders in antiphospholipid (Hughes) syndrome (APS). Lupus 2014; 23:697-702. [DOI: 10.1177/0961203314524468] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/28/2014] [Indexed: 12/29/2022]
Abstract
Background Antiphospholipid syndrome (APS) is an autoimmune hypercoagulable disorder that has been shown to cause a large number of cardiac and neurological manifestations. Two recent studies have demonstrated abnormalities in cardiovascular autonomic function testing in APS patients without other cardiovascular or autoimmune disease. However, an association between autonomic disorders such as postural tachycardia syndrome and APS has not previously been described. Methods and results Data were obtained by retrospective chart review. We identified 15 patients who have been diagnosed with APS and an autonomic disorder. The median age of the patients at the time of data analysis was 39 years. The autonomic disorders seen in these patients included postural tachycardia syndrome, neurocardiogenic syncope and orthostatic hypotension. The majority of patients (14/15) were female and the majority (14/15) had non-thrombotic neurological manifestations of APS, most commonly migraine, memory loss and balance disorder. Many also had livedo reticularis (11/15) and Raynaud’s phenomenon (nine of 15). In some patients, the autonomic manifestations improved with anticoagulation and/or anti-platelet therapy; in others they did not. Two patients with postural tachycardia syndrome who failed to improve with the usual treatment of APS have been treated with intravenous immunoglobulin with significant improvement in their autonomic symptoms. Conclusion We believe that autonomic disorders in APS may represent an important clinical association with significant implications for treatment.
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Affiliation(s)
- JR Schofield
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - S Blitshteyn
- Department of Neurology, State University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Y Shoenfeld
- Sackler Faculty in Medicine, Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases, Tel-Aviv University, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - GRV Hughes
- The London Lupus Centre, London Bridge Hospital, London, UK
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Kimpinski K, Ives CT. A case of acute reversible pure adrenergic failure. Auton Neurosci 2013; 179:163-5. [DOI: 10.1016/j.autneu.2013.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 06/10/2013] [Accepted: 06/12/2013] [Indexed: 11/25/2022]
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Autonomic involvement in subacute and chronic immune-mediated neuropathies. Autoimmune Dis 2013; 2013:549465. [PMID: 23853716 PMCID: PMC3703364 DOI: 10.1155/2013/549465] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 05/28/2013] [Indexed: 12/03/2022] Open
Abstract
Autonomic function can be impaired in many disorders in which sympathetic, parasympathetic, and enteric arms of the autonomic nervous system are affected. Signs and symptoms of autonomic involvement are related to impairment of cardiovascular, gastrointestinal, urogenital, thermoregulatory, sudomotor, and pupillomotor autonomic functions. Availability of noninvasive, sensitive, and reproducible tests can help to recognize these disorders and to better understand specific mechanisms of some, potentially treatable, immune-mediated autonomic neuropathies. This paper describes autonomic involvement in immune-mediated neuropathies with a subacute or chronic course.
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Abstract
Postural tachycardia syndrome is a chronic condition with frequent symptoms of orthostatic intolerance or sympathetic activation and excessive tachycardia while standing, without significant hypotension. Orthostatic symptoms include dizziness, lightheadedness, blurring of vision, near faints, weakness in legs, poor concentration, nausea, and headaches. Somatic symptoms include fatigue, sleep disorder, widespread pain, abdominal pain, and menstrual irregularities. Psychological problems may overlap with physical complaints. This review discusses the normal physiology of orthostatic change, different pathophysiological mechanisms of postural tachycardia syndrome, including hypovolemia, venous pooling, autonomic neuropathy, and hyperadrenergic responses. In addition, an outline for management tailored to the patient's clinical syndrome is presented, along with concluding thoughts on future research needs.
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Affiliation(s)
- Imad T Jarjour
- Department of Pediatrics, Clinic for Autonomic Dysfunction, Texas Children's Hospital, Houston, TX 77030-2399, USA.
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