1
|
Martinez ARM, de Lima FD, Martins MP, Pereira IE, Miotto N, Mazo DFC, Vigani AG, da Costa LBE, Stucchi RSB, Almeida JRS, Nucci A, França MC. Sensory neuronopathy is a specific and disabling neurological manifestation of autoimmune hepatitis. Eur J Neurol 2020; 27:2072-2078. [PMID: 32441838 DOI: 10.1111/ene.14355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/15/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Neurological manifestations have been identified in the context of autoimmune hepatitis (AIH). Previous case reports highlighted the association between AIH and sensory neuronopathy (SN). Despite that, little is known about the frequency of AIH-related SN and its clinical/neurophysiological profile. Moreover, it is not clear whether SN is an AIH-specific manifestation or related to chronic liver damage. METHODS Seventy consecutive AIH patients were enrolled and their characteristics were compared with 52 consecutive patients with chronic active hepatitis B. All subjects underwent clinical and neurophysiological evaluation. Further comparisons were performed between AIH SN and AIH non-SN patients. RESULTS Mean ages and male:female proportions in the AIH and chronic active hepatitis B groups were 42.2 ± 16.3/51.7 ± 13.6 years and 14:56/29:23, respectively. The frequencies of carpal tunnel syndrome, radiculopathy and polyneuropathy were similar between groups. In contrast, SN was identified only in AIH patients (5/70 vs. 0/52, P = 0.04); the overall prevalence of AIH-related SN was 7% with an average profile of a woman in her 40s with asymmetric onset of sensory deficits that chronically evolved to disabling proprioceptive ataxia associated with marked dysautonomia. Neurological disability and hepatocellular damage did not follow in parallel. Anti-fibroblast growth factor receptor type 3 antibodies were found in 3/5 (60%) of the patients with AIH-related SN. Clinical or demographic predictors of SN in the context of AIH could not be identified. CONCLUSION Sensory neuronopathy, but not other peripheral nervous system diseases, is a specific AIH neurological manifestation. It is often disabling and, in contrast to hepatocellular injury, does not respond to immunosuppression.
Collapse
Affiliation(s)
- A R M Martinez
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - F D de Lima
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - M P Martins
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - I E Pereira
- Department of Internal Medicine - Gastroenterology Division (Gastrocentro), University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - N Miotto
- Department of Internal Medicine - Infectious Diseases Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - D F C Mazo
- Department of Internal Medicine - Gastroenterology Division (Gastrocentro), University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - A G Vigani
- Department of Internal Medicine - Infectious Diseases Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - L B E da Costa
- Department of Pathology - Hepatic Disorders Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - R S B Stucchi
- Department of Internal Medicine - Infectious Diseases Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - J R S Almeida
- Department of Internal Medicine - Gastroenterology Division (Gastrocentro), University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - A Nucci
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - M C França
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| |
Collapse
|
2
|
Martinez ARM, Ribeiro MC, Lima FDD, Martins CR, Martins MP, Nucci A, França MC. Misdiagnosis and diagnostic delay in non-paraneoplastic sensory neuronopathies. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:451-455. [PMID: 31365635 DOI: 10.1590/0004-282x20190065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 03/07/2019] [Indexed: 06/10/2023]
Abstract
METHODS Sensory neuronopathies (SN) are a group of peripheral nerve disorders characterized by multifocal non-length-dependent sensory deficits and sensory ataxia. Its recognition is essential not only for proper management but also to guide the etiological investigation. The uncommon SN clinical picture and its rarity set the conditions for the misdiagnosis and the diagnostic delay, especially in non-paraneoplastic SN. Therefore, our objectives were to characterize the diagnostic odyssey for non-paraneoplastic SN patients, as well as to identify possible associated factors. We consecutively enrolled 48 non-paraneoplastic SN patients followed in a tertiary neuromuscular clinic at the University of Campinas (Brazil). All patients were instructed to retrieve their previous medical records, and we collected the data regarding demographics, disease onset, previous incorrect diagnoses made and the recommended treatments. RESULTS There were 34 women, with a mean age at the diagnosis of 45.9 ± 12.2 years, and 28/48 (58%) of the patients were idiopathic. Negative sensory symptoms were the heralding symptoms in 25/48 (52%); these were asymmetric in 36/48 (75%) and followed a chronic course in 35/48 (73%). On average, it took 5.4 ± 5.3 years for SN to be diagnosed; patients had an average of 3.4 ± 1.5 incorrect diagnoses. A disease onset before the age of 40 was associated to shorter diagnosis delay (3.7 ± 3.4 vs. 7.8 ± 6.7 years, p = 0.01). CONCLUSIONS These results suggest that diagnostic delay and misdiagnosis are frequent in non-paraneoplastic SN patients. As in other rare conditions, increased awareness in all the healthcare system levels is paramount to ensure accurate diagnosis and to improve care of these patients.
Collapse
Affiliation(s)
- Alberto Rolim Muro Martinez
- Universidade Estadual de Campinas, Departamento de Neurologia, Serviço de Doenças Neuromusculares, Campinas SP, Brasil
| | - Mayani Costa Ribeiro
- Universidade Estadual de Campinas, Departamento de Neurologia, Serviço de Doenças Neuromusculares, Campinas SP, Brasil
| | - Fabricio Diniz de Lima
- Universidade Estadual de Campinas, Departamento de Neurologia, Serviço de Doenças Neuromusculares, Campinas SP, Brasil
| | - Carlos Roberto Martins
- Universidade Estadual de Campinas, Departamento de Neurologia, Serviço de Doenças Neuromusculares, Campinas SP, Brasil
| | - Melina Pazian Martins
- Universidade Estadual de Campinas, Departamento de Neurologia, Serviço de Doenças Neuromusculares, Campinas SP, Brasil
| | - Anamarli Nucci
- Universidade Estadual de Campinas, Departamento de Neurologia, Serviço de Doenças Neuromusculares, Campinas SP, Brasil
| | - Marcondes Cavalcante França
- Universidade Estadual de Campinas, Departamento de Neurologia, Serviço de Doenças Neuromusculares, Campinas SP, Brasil
| |
Collapse
|
3
|
Zis P, Hadjivassiliou M, Sarrigiannis PG, Barker ASJE, Rao DG. Rapid neurophysiological screening for sensory ganglionopathy: A novel approach. Brain Behav 2017; 7:e00880. [PMID: 29299392 PMCID: PMC5745252 DOI: 10.1002/brb3.880] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/07/2017] [Accepted: 10/16/2017] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND AND AIM Pure sensory neuropathies involving the dorsal root ganglia are commonly referred to as sensory ganglionopathies (SG). Causes of SG can be inherited (as seen in Friedreich's ataxia) or acquired (e.g. immune-mediated or paraneoplastic). Diagnostic criteria for confirming SG have been published and consist of a combination of clinical and neurophysiological parameters. The aim of our study was to develop a neurophysiological method for rapid screening for diagnosis of SG. METHODS For each subject we obtained the sensory nerve action potentials (SNAPs) of five nerves (median, ulnar, radial, sural and superficial peroneal) bilaterally. In the presence of an entrapment neuropathy we obtained the SNAP of the medial antebrachial cutaneous nerves bilaterally. We estimated the number of pairs of nerves showing a SNAP asymmetry of >50% (difference of SNAPs/ lower SNAP). RESULTS Sixty-eight subjects, 34 patients with SG and 34 age and sex-matched controls, participated in the study. Among all subjects using a receiver operating characteristic (ROC) curve analysis, the area under the curve was 0.984 (95% CI, 0.960-1.000; SE, 0.012; p < .001). In order to detect SG, presence of SNAP asymmetry of >50% in 2 pairs of nerves, not explained by an entrapment neuropathy, shows a sensitivity of 97.1%, a specificity of 94.1%, a positive predictive value of 94.3% and a negative predictive value of 97.0. CONCLUSION The number of pairs of nerves showing a SNAP asymmetry of >50% may be used as a novel rapid screening tool of patients with SG.
Collapse
Affiliation(s)
- Panagiotis Zis
- Academic Department of Neurosciences Sheffield Teaching Hospitals NHS Foundation Trust Sheffield South Yorkshire UK
| | - Marios Hadjivassiliou
- Academic Department of Neurosciences Sheffield Teaching Hospitals NHS Foundation Trust Sheffield South Yorkshire UK
| | | | | | - Dasappaiah Ganesh Rao
- Academic Department of Neurosciences Sheffield Teaching Hospitals NHS Foundation Trust Sheffield South Yorkshire UK
| |
Collapse
|
4
|
Martinez ARM, Costa MCM, Novaes MAC, Lima HC, Nucci A, França MC. A novel phenotype Of Zika virus-related neurological disease: Sensory neuronopathy. Muscle Nerve 2017; 57:E100-E101. [DOI: 10.1002/mus.25958] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 08/20/2017] [Accepted: 09/02/2017] [Indexed: 11/08/2022]
Affiliation(s)
| | | | | | | | - Anamarli Nucci
- Department of Neurology; University of Campinas; Campinas São Paulo Brazil
| | | |
Collapse
|
5
|
Casseb RF, de Paiva JLR, Branco LMT, Martinez ARM, Reis F, de Lima-Junior JC, Castellano G, Junior MCF. Spinal cord diffusion tensor imaging in patients with sensory neuronopathy. Neuroradiology 2016; 58:1103-1108. [PMID: 27561739 DOI: 10.1007/s00234-016-1738-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/09/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION We investigated whether MR diffusion tensor imaging (DTI) analysis of the cervical spinal cord could aid the (differential) diagnosis of sensory neuronopathies, an underdiagnosed group of diseases of the peripheral nervous system. METHODS We obtained spinal cord DTI and T2WI at 3 T from 28 patients, 14 diabetic subjects with sensory-motor distal polyneuropathy, and 20 healthy controls. We quantified DTI-based parameters and looked at the hyperintense T2W signal at the spinal cord posterior columns. Fractional anisotropy and mean diffusivity values at C2-C3 and C3-C4 levels were compared between groups. We also compared average fractional anisotropy (mean of values at C2-C3 and C3-C4 levels). A receiver operating characteristic (ROC) curve was used to determine diagnostic accuracy of average fractional anisotropy, and we compared its sensitivity against the hyperintense signal in segregating patients from the other subjects. RESULTS Mean age and disease duration were 52 ± 10 and 11.4 ± 9.3 years in the patient group. Eighteen subjects had idiopathic disease and 6 dysimmune etiology. Fractional anisotropy at C3-C4 level and average fractional anisotropy were significantly different between patients and healthy controls (p < 0.001 and <0.001) and between patients and diabetic subjects (p = 0.019 and 0.027). Average fractional anisotropy presented an area under the curve of 0.838. Moreover, it had higher sensitivity than visual detection of the hyperintense signal (0.86 vs. 0.54), particularly for patients with short disease duration. CONCLUSION DTI-based analysis enables in vivo detection of posterior column damage in sensory neuronopathy patients and is a useful diagnostic test for this condition. It also helps the differential diagnosis between sensory neuronopathy and distal polyneuropathies.
Collapse
Affiliation(s)
- Raphael Fernandes Casseb
- Department of Neurology, School of Medicine, University of Campinas - UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitaria "Zeferino Vaz", Campinas, SP, 13083-887, Brazil.,Neurophysics Group, Department of Cosmic Rays and Chronology, Institute of Physics Gleb Wataghin, University of Campinas - UNICAMP, Campinas, SP, Brazil
| | - Jean Levi Ribeiro de Paiva
- Department of Neurology, School of Medicine, University of Campinas - UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitaria "Zeferino Vaz", Campinas, SP, 13083-887, Brazil
| | - Lucas Melo Teixeira Branco
- Department of Neurology, School of Medicine, University of Campinas - UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitaria "Zeferino Vaz", Campinas, SP, 13083-887, Brazil
| | - Alberto Rolim Muro Martinez
- Department of Neurology, School of Medicine, University of Campinas - UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitaria "Zeferino Vaz", Campinas, SP, 13083-887, Brazil
| | - Fabiano Reis
- Department of Radiology, School of Medicine, University of Campinas - UNICAMP, Campinas, SP, Brazil
| | - José Carlos de Lima-Junior
- Laboratory of Cell Signaling, Department of Internal Medicine, University of Campinas - UNICAMP, Campinas, SP, Brazil
| | - Gabriela Castellano
- Neurophysics Group, Department of Cosmic Rays and Chronology, Institute of Physics Gleb Wataghin, University of Campinas - UNICAMP, Campinas, SP, Brazil
| | - Marcondes Cavalcante França Junior
- Department of Neurology, School of Medicine, University of Campinas - UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitaria "Zeferino Vaz", Campinas, SP, 13083-887, Brazil.
| |
Collapse
|
6
|
Casseb RF, Martinez ARM, de Paiva JLR, França MC. Neuroimaging in Sensory Neuronopathy. J Neuroimaging 2015; 25:704-9. [PMID: 25678358 DOI: 10.1111/jon.12210] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/18/2014] [Accepted: 11/27/2014] [Indexed: 12/13/2022] Open
Abstract
Sensory neuronopathies (SN) are a group of disorders characterized by primary damage to the dorsal root ganglia neurons. Clinical features include multifocal areas of hypoaesthesia, pain, dysautonomia, and sensory ataxia, which is the major source of disability. Diagnosis relies upon clinical assessment and nerve conductions studies, but sometimes it is difficult to distinguish SN from similar conditions, such as axonal polyneuropathies and some myelopathies. In this scenario, underdiagnosis is certainly an important issue for SN patients and additional diagnostic tools are needed. MRI is able to evaluate the dorsal columns of the spinal cord and has proven useful in the workup of SN patients. Although T2 weighted hyperintensity restricted to the posterior fasciculi without contrast enhancement is the typical finding, additional abnormalities have been recently reported. The aim of this review is to gather available information on neuroimaging findings of SN, discuss their clinical correlates and the potential impact of novel MRI-based techniques.
Collapse
Affiliation(s)
- Raphael Fernandes Casseb
- Department of Neurology and Neuroimaging Laboratory-School of Medicine, University of Campinas, Campinas, Brazil
| | - Alberto Rolim Muro Martinez
- Department of Neurology and Neuroimaging Laboratory-School of Medicine, University of Campinas, Campinas, Brazil
| | - Jean Levi Ribeiro de Paiva
- Department of Neurology and Neuroimaging Laboratory-School of Medicine, University of Campinas, Campinas, Brazil
| | - Marcondes Cavalcante França
- Department of Neurology and Neuroimaging Laboratory-School of Medicine, University of Campinas, Campinas, Brazil
| |
Collapse
|