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de Oliveira Silva T, Darzé ES, Machado Costa M, Junior LJ, Ximenes AAB, Fernandes F, de Seixas Rocha M, Noya-Rabelo MM, Fonteles Ritt LE. Scintigraphic and Echocardiographic Study of Patients with Pathogenic or Probably Pathogenic Variants of the TTR Gene without Overt Cardiac Involvement. Arq Bras Cardiol 2024; 121:e20230216. [PMID: 38775614 PMCID: PMC11081098 DOI: 10.36660/abc.20230216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 10/09/2023] [Accepted: 12/13/2023] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Transthyretin amyloidosis (ATTR) is an infiltrative disease caused by abnormal protein deposition mainly in the heart and peripheral nervous system. When it affects the heart, the disease presents as restrictive cardiomyopathy; when it affects the peripheral and autonomic nervous system, it manifests as polyneuropathy, and is called familial amyloid polyneuropathy (FAP). There are two ATTR subtypes: wild-type ATTR, where there is no mutation, and mutant ATTR (ATTRm), which is characterized by a mutation in the gene encoding the transthyretin protein (TTR). In both subtypes, cardiac involvement is the major marker of poor prognosis. OBJECTIVES To assess the prevalence of subclinical cardiac involvement in a sample of patients with TTR gene mutation by using pyrophosphate scintigraphy and strain echocardiography; to compare scintigraphy and strain findings; to evaluate the association between neurological manifestations (FAP) and subclinical cardiac involvement; and to analyze whether there is an association between any specific mutation and cardiac involvement. METHODS This is a cross-sectional study with carriers of the TTR gene mutation, without cardiovascular symptoms or changes in electrocardiographic or conventional echocardiographic parameters. All patients underwent pyrophosphate scintigraphy and strain echocardiography. Subclinical cardiac involvement was defined as a Perugini score ≥ 2, heart-to-contralateral lung (H/CL) ratio ≥ 1.5 at 1 h, H/CL ≥1.3 at 3 h, or global longitudinal strain (GLS) ≤ -17%. Descriptive and analytical analyses were performed and Fisher's exact test and Mann-Whitney test were applied. A value of p < 0.05 was considered significant. RESULTS The 23 patients evaluated had a median age of 51 years (IQR 37-57 years), 15 (65.2%) were female, 12 (52.2%) were Pardo, nine (39.1%) had systemic arterial hypertension, and nine (39.1%) had a previous diagnosis of FAP. Of the nine patients with FAP, 8 (34.8%) were on tafamidis. The associated mutations were Val142IIe, Val50Met, and IIe127Val. The median GLS in the sample was -19% (-16% to -20%). Of the 23 patients, nine (39.1%; 95% CI = 29-49%) met criteria for cardiac involvement, six (26%) by the GLS-based criteria only. There was no association between having FAP and being an asymptomatic carrier, as assessed by strain echocardiography and pyrophosphate scintigraphy (p = 0.19). The prevalence of systemic arterial hypertension, diabetes mellitus, dyslipidemia, smoking, and reduced GLS did not differ between groups. Septal e' wave velocity was the only variable that significantly differed between individuals with and without reduced GLS, with an area under the ROC curve of 0.80 (95% CI = 0.61-0.98, p = 0.027). The best diagnostic accuracy was achieved with a septal e' velocity ≤ 8.5 cm/s. There was no association between mutation type and preclinical cardiac involvement, nor between tafamidis use and lower degree of cardiac involvement (37.5% versus 40.0%, p = 0.90). CONCLUSION Subclinical cardiac involvement was common in a sample of TTR mutation carriers without cardiac involvement. Reduced left ventricular GLS was the most frequent finding. There was no association between the presence of amyloid polyneuropathy and subclinical cardiac involvement. Type of mutation was not associated with early cardiac involvement. In this sample, the use of tafamidis 20 mg/day was not associated with a lower prevalence of subclinical cardiac involvement.
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Affiliation(s)
- Tonnison de Oliveira Silva
- Hospital Cardio PulmonarInstituto D'Or de Ensino e PesquisaSalvadorBABrasilHospital Cardio Pulmonar - Instituto D'Or de Ensino e Pesquisa – IDOR, Salvador, BA – Brasil
- Escola Bahiana de Medicina e Súde PúblicaSalvadorBABrasilEscola Bahiana de Medicina e Súde Pública, Salvador, BA – Brasil
| | - Eduardo Sahade Darzé
- Hospital Cardio PulmonarInstituto D'Or de Ensino e PesquisaSalvadorBABrasilHospital Cardio Pulmonar - Instituto D'Or de Ensino e Pesquisa – IDOR, Salvador, BA – Brasil
| | - Marcela Machado Costa
- Hospital Cardio PulmonarInstituto D'Or de Ensino e PesquisaSalvadorBABrasilHospital Cardio Pulmonar - Instituto D'Or de Ensino e Pesquisa – IDOR, Salvador, BA – Brasil
- Escola Bahiana de Medicina e Súde PúblicaSalvadorBABrasilEscola Bahiana de Medicina e Súde Pública, Salvador, BA – Brasil
| | - Luiz José Junior
- Hospital Cardio PulmonarInstituto D'Or de Ensino e PesquisaSalvadorBABrasilHospital Cardio Pulmonar - Instituto D'Or de Ensino e Pesquisa – IDOR, Salvador, BA – Brasil
| | - Antonio A. B. Ximenes
- Hospital Cardio PulmonarInstituto D'Or de Ensino e PesquisaSalvadorBABrasilHospital Cardio Pulmonar - Instituto D'Or de Ensino e Pesquisa – IDOR, Salvador, BA – Brasil
| | - Fábio Fernandes
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Mário de Seixas Rocha
- Escola Bahiana de Medicina e Súde PúblicaSalvadorBABrasilEscola Bahiana de Medicina e Súde Pública, Salvador, BA – Brasil
| | - Marcia M. Noya-Rabelo
- Escola Bahiana de Medicina e Súde PúblicaSalvadorBABrasilEscola Bahiana de Medicina e Súde Pública, Salvador, BA – Brasil
- Hospital São RafaelInstituto D'Or de Ensino e PesquisaSalvadorBABrasilHospital São Rafael - Instituto D'Or de Ensino e Pesquisa – IDOR, Salvador, BA – Brasil
| | - Luiz Eduardo Fonteles Ritt
- Hospital Cardio PulmonarInstituto D'Or de Ensino e PesquisaSalvadorBABrasilHospital Cardio Pulmonar - Instituto D'Or de Ensino e Pesquisa – IDOR, Salvador, BA – Brasil
- Escola Bahiana de Medicina e Súde PúblicaSalvadorBABrasilEscola Bahiana de Medicina e Súde Pública, Salvador, BA – Brasil
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Dias M, Pinto LF, Pinto MV, Gervais R, Accioli P, Amorim G, Guedes M, Gomes CP, Pedrosa RC, Waddington-Cruz M. Real-life experience with inotersen at CEPARM, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-7. [PMID: 38579737 PMCID: PMC10997406 DOI: 10.1055/s-0044-1781463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/03/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Hereditary transthyretin amyloidosis (ATTRv) is an inherited, progressive, and fatal disease still largely underdiagnosed. Mutations in the transthyretin (TTR) gene cause the TTR protein to destabilize, misfold, aggregate, and deposit in body tissues, which makes ATTRv a disease with heterogeneous clinical phenotype. OBJECTIVE To describe the long-term efficacy and safety of inotersen therapy in patients with ATTRv peripheral neuropathy (ATTRv-PN). METHODS Patients who completed the NEURO-TTR pivotal study and the NEURO-TTR OLE open-label extension study migrated to the present study and were followed-up for at least 18 more months to an average of 67 months and up to 76 months since day 1 of the inotersen therapy (D1-first dose of inotersen). Disease progression was evaluated by standard measures. RESULTS Ten ATTRv-PN patients with Val30Met mutation were included. The mean disease duration on D1 was of 3 years, and the mean age of the patients was of 46.8 years. During an additional 18-month follow up, neurological function, based on the Neuropathy Impairment Score and the Polyneuropathy Disability Score, functionality aspects (Karnofsky Performance Status), and nutritional and cardiac aspects were maintained. No new safety signs have been noted. CONCLUSION The treatment with inotersen was effective and well tolerated for the average of 67 months and up to 76 months. Our results are consistent with those of larger phase-III trials.
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Affiliation(s)
- Moises Dias
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Serviço de Nefrologia, Rio de Janeiro RJ, Brazil.
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello (CEPARM), Rio de Janeiro RJ, Brazil.
| | - Luiz Felipe Pinto
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello (CEPARM), Rio de Janeiro RJ, Brazil.
| | - Marcus Vinícius Pinto
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello (CEPARM), Rio de Janeiro RJ, Brazil.
- Mayo Clinic, Department of Neurology, Rochester MN, United States.
| | - Renata Gervais
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Serviço de Nefrologia, Rio de Janeiro RJ, Brazil.
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello (CEPARM), Rio de Janeiro RJ, Brazil.
| | - Paula Accioli
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello (CEPARM), Rio de Janeiro RJ, Brazil.
| | - Gabriela Amorim
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello (CEPARM), Rio de Janeiro RJ, Brazil.
| | - Mariana Guedes
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello (CEPARM), Rio de Janeiro RJ, Brazil.
| | - Carlos Perez Gomes
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Serviço de Nefrologia, Rio de Janeiro RJ, Brazil.
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello (CEPARM), Rio de Janeiro RJ, Brazil.
| | - Roberto Coury Pedrosa
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello (CEPARM), Rio de Janeiro RJ, Brazil.
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Instituto de Cardiologia Edson Saad, Rio de Janeiro RJ, Brazil.
| | - Márcia Waddington-Cruz
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Programa de Pós-graduação/Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello (CEPARM), Rio de Janeiro RJ, Brazil.
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Ando Y, Waddington-Cruz M, Sekijima Y, Koike H, Ueda M, Konishi H, Ishii T, Coelho T. Optimal practices for the management of hereditary transthyretin amyloidosis: real-world experience from Japan, Brazil, and Portugal. Orphanet J Rare Dis 2023; 18:323. [PMID: 37828588 PMCID: PMC10571420 DOI: 10.1186/s13023-023-02910-3] [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: 04/10/2023] [Accepted: 09/05/2023] [Indexed: 10/14/2023] Open
Abstract
Hereditary transthyretin (ATTRv) amyloidosis is a rare and autosomal dominant disorder associated with mutations in the transthyretin gene. Patients present with diverse symptoms related to sensory, motor, and autonomic neuropathy, as well as gastrointestinal, ocular, cardiac, renal and orthopedic symptoms, resulting from the deposition of transthyretin amyloid fibrils in multiple organs. The progressive nature of ATTRv amyloidosis necessitates pre- and post-onset monitoring of the disease. This review article is primarily based on a collation of discussions from a medical advisory board meeting in August 2021. In this article, we summarize the best practices in amyloidosis centers in three major endemic countries for ATTRv amyloidosis (Japan, Brazil, and Portugal), where most patients carry the Val30Met mutation in the transthyretin gene and the patients' genetic background was proven to be the same. The discussions highlighted the similarities and differences in the management of asymptomatic gene mutation carriers among the three countries in terms of the use of noninvasive tests and tissue biopsies and timing of starting the investigations. In addition, this article discusses a set of practical tests and examinations for monitoring disease progression applicable to neurologists working in diverse medical settings and generalizable in non-endemic countries and areas. This set of assessments consists of periodic (every 6 to 12 months) evaluations of patients' nutritional status and autonomic, renal, cardiac, ophthalmologic, and neurological functions. Physical examinations and patient-reported outcome assessments should be also scheduled every 6 to 12 months. Programs for monitoring gene mutation carriers and robust referral networks can aid in appropriate patient management in pre- to post-onset stages. For pre- and post-symptom onset testing for ATTRv amyloidosis, various noninvasive techniques are available; however, their applicability differs depending on the medical setting in each country and region, and the optimal option should be selected in view of the clinical settings, medical environment, and available healthcare resources in each region.
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Affiliation(s)
- Yukio Ando
- Department of Amyloidosis Research, Faculty of Pharmaceutical Sciences, Nagasaki International University, 2825-7 Huis Ten Bosch Machi, Sasebo City, Nagasaki, 859-3298, Japan.
| | - Marcia Waddington-Cruz
- Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | | | | | - Teresa Coelho
- Andrade's Center for Familial Amyloidosis, Hospital Santo António, Centro Hospitalar Universitário Do Porto, Porto, Portugal
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Pinto MV, França MC, Gonçalves MVM, Machado-Costa MC, Freitas MRGD, Gondim FDAA, Marrone CD, Martinez ARM, Moreira CL, Nascimento OJM, Covaleski APP, Oliveira ASBD, Pupe CCB, Rodrigues MMJ, Rotta FT, Scola RH, Marques W, Waddington-Cruz M. Brazilian consensus for diagnosis, management and treatment of hereditary transthyretin amyloidosis with peripheral neuropathy: second edition. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:308-321. [PMID: 37059440 PMCID: PMC10104762 DOI: 10.1055/s-0043-1764412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Hereditary transthyretin amyloidosis with peripheral neuropathy (ATTRv-PN) is an autosomal dominant inherited sensorimotor and autonomic polyneuropathy with over 130 pathogenic variants identified in the TTR gene. Hereditary transthyretin amyloidosis with peripheral neuropathy is a disabling, progressive and life-threatening genetic condition that leads to death in ∼ 10 years if untreated. The prospects for ATTRv-PN have changed in the last decades, as it has become a treatable neuropathy. In addition to liver transplantation, initiated in 1990, there are now at least 3 drugs approved in many countries, including Brazil, and many more are being developed. The first Brazilian consensus on ATTRv-PN was held in the city of Fortaleza, Brazil, in June 2017. Given the new advances in the area over the last 5 years, the Peripheral Neuropathy Scientific Department of the Brazilian Academy of Neurology organized a second edition of the consensus. Each panelist was responsible for reviewing the literature and updating a section of the previous paper. Thereafter, the 18 panelists got together virtually after careful review of the draft, discussed each section of the text, and reached a consensus for the final version of the manuscript.
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Affiliation(s)
- Marcus Vinicius Pinto
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Rio de Janeiro RJ, Brazil
- Mayo Clinic, Department of Neurology, Rochester, Minnesota, United States
| | | | | | | | - Marcos Raimundo Gomes de Freitas
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Rio de Janeiro RJ, Brazil
| | | | - Carlo Domenico Marrone
- Pontifícia Universidade Católica do Rio Grande do Sul, Hospital São Lucas, Clínica Marrone e Ambulatório de Doenças Neuromusculare, Porto Alegre RS, Brazil
| | | | | | | | | | | | | | | | - Francisco Tellechea Rotta
- Hospital Moinhos de Vento, Porto Alegre RS, Brazil
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre RS, Brazil
| | | | - Wilson Marques
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | - Márcia Waddington-Cruz
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello, Rio de Janeiro RJ, Brazil
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da Silva Batista JA, Carrera LR, Viriato AR, Novaes MAC, de Morais RJL, Oliveira FT, Marques W, Machado- Costa MC. Involvement of cranial nerves in ATTR Ile127Val amyloidosis. Eur J Med Genet 2022; 65:104524. [DOI: 10.1016/j.ejmg.2022.104524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/26/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
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Sequeira VCC, Penetra MA, Duarte L, Azevedo FRD, Sayegh RSR, Pedrosa RC, Cruz MW. Hereditary transthyretin-mediated amyloidosis with polyneuropathy: baseline anthropometric, demographic and disease characteristics of patients from a reference center. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 80:262-269. [PMID: 34755769 DOI: 10.1590/0004-282x-anp-2020-0590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/25/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Hereditary transthyretin-mediated (hATTR) amyloidosis with polyneuropathy is a rare, inherited, multisystem, and often fatal disease caused by a variant in transthyretin (TTR) gene. Baseline characteristics of patients, especially anthropometric data, are scarce in the literature, and they are relevant to define effective treatment strategies. OBJECTIVE This study aimed to describe baseline demographic, anthropometric, and disease characteristics in a cohort of patients from a reference center in Brazil. METHODS Symptomatic patients not previously included in clinical trials and eligible for treatment were enrolled. Ethnicity, state of residence, age, sex, weight, height, body mass index (BMI), TTR variant, and Polyneuropathy Disability Score (PND) at diagnosis were analyzed. RESULTS Among the 108 patients enrolled, 58.33% were male, 60.19% were Caucasian, and 83.33% lived in the Southeast region. Mean age was 51.61 (±16.37) years, mean weight was 65.76 (±15.16) kg, mean height was 168.33 (±10.26) cm, and mean BMI was 23.11 (±4.45) kg/m2. The most prevalent variant was V30M (86.11%). Patients with PND score 0 presenting autonomic neuropathy were 14.81%. Patients with PND score I-II and III-IV were 52.78 and 32.41%, respectively. Mean weight and BMI were significantly lower in patients with sensory-motor manifestations. CONCLUSIONS This is the largest cohort of patients in Brazil for whom anthropometric characteristics have been described. Baseline demographic, anthropometric, and disease data indicate that delay in diagnosis of hATTR amyloidosis with polyneuropathy is still a problem and that efforts must be made to expedite diagnosis and maximize opportunities for new disease-modifying treatments.
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Affiliation(s)
- Vanessa Cristina Cunha Sequeira
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Paramiloidose Antônio Rodrigues de Mello, Rio de Janeiro RJ, Brazil.,Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Instituto do Coração Edson Saad, Rio de Janeiro RJ, Brazil
| | - Maria Alice Penetra
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Paramiloidose Antônio Rodrigues de Mello, Rio de Janeiro RJ, Brazil
| | - Lisa Duarte
- Alnylam Pharmaceuticals Inc, São Paulo SP, Brazil
| | | | | | - Roberto Coury Pedrosa
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Paramiloidose Antônio Rodrigues de Mello, Rio de Janeiro RJ, Brazil.,Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Instituto do Coração Edson Saad, Rio de Janeiro RJ, Brazil
| | - Márcia Waddington Cruz
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Paramiloidose Antônio Rodrigues de Mello, Rio de Janeiro RJ, Brazil
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Jay PY, Maier MA, Saltonstall L, Duarte L, Antonino I, Vest J. Gene Silencing Therapeutics in Cardiology: A Review Article. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20200306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Santos LOD, Fernandes TRMDO, Barbosa TRDS, Batista JADS, Souza CDFD. Pure neural leprosy or amyloid neuropathy? Systematic review and clinical case report. ACTA ACUST UNITED AC 2021; 67:140-149. [PMID: 34161469 DOI: 10.1590/1806-9282.67.01.20200422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 10/22/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review the literature and to report a clinical case with initial suspicion of pure neural leprosy and final diagnosis of amyloid neuropathy. METHODS The study was conducted in two stages. In stage one, a systematic literature review was carried out, with searches performed in the PubMed, Medline, and Lilacs databases, as well as in the leprosy sectoral library of the Virtual Health Library, using the following descriptors: neuritic leprosy, pure neural leprosy, primary neural leprosy, pure neuritic leprosy, amyloid polyneuropathy, amyloid neuropathies, and amyloid polyneuropathy. The search was carried out on May 28, 2020. Clinical trials, cohort studies, cross-sectional studies, clinical cases, and case studies published in Portuguese, English or Spanish between 2010 and 2020 were included. Stage two reports a case with initial suspicion of pure neural leprosy. Laboratory tests, electroneuromyography, ultrasound, and biopsy of the sural nerve were requested. RESULTS Twenty-three scientific texts were included. No publications were found that contained both topics together. The challenging diagnosis of pure neural leprosy and the possibility of using auxiliary resources in diagnosis were the most emphasized themes in the studies. In the clinical case, the patient's electroneuromyography showed sensitive and motor polyneuropathy of the lower limbs, which was predominantly sensory and axonal, symmetrical, of moderate intensity, and the mixed type (axonal-demyelinating). Ultrasonography of the sural nerve revealed changes in the contour of the deep fibular nerves; biopsy of the sural nerve showed an accumulation of amorphous eosinophilic material in the nerve path, and Congo red stain showed apple-green birefringence of the deposit under polarized light. The final diagnosis was amyloid neuropathy. CONCLUSIONS The final clinical diagnosis was amyloid neuropathy. The diagnosis of pure neural leprosy in endemic areas in Brasil is still a challenge for the health system.
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Pinto MV, Dyck PJB, Liewluck T. Neuromuscular amyloidosis: Unmasking the master of disguise. Muscle Nerve 2021; 64:23-36. [PMID: 33458861 DOI: 10.1002/mus.27150] [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: 09/28/2020] [Revised: 12/11/2020] [Accepted: 12/17/2020] [Indexed: 12/16/2022]
Abstract
Amyloidosis refers to an etiologically heterogeneous group of protein misfolding diseases, pathologically characterized by extracellular amyloid fibrils producing congophillic amorphous deposits in organs and tissues, which may lead to severe organ dysfunction and mortality. Clinical presentations vary and are often nonspecific, depending on what organs or tissues are affected. In systemic amyloidosis, the peripheral nervous system is commonly affected, whereas the skeletal muscles are only rarely involved. Immunoglobulin light chain (AL) amyloidosis and hereditary transthyretin (ATTRv) amyloidosis are the most frequent types of systemic amyloidosis involving the neuromuscular system. Localized amyloidosis can occur in skeletal muscle, so-called isolated amyloid myopathy. Amyloid neuropathy typically involves small myelinated and unmyelinated sensory and autonomic nerve fibers early in the course of the disease, followed by large myelinated fiber sensory and motor deficits. The relentlessly progressive nature with motor, painful sensory and severe autonomic dysfunction, profound weight loss, and systemic features are distinct characteristics of amyloid neuropathy. Amyloid myopathy presentation differs between systemic amyloidosis and isolated amyloid myopathy. Long-standing symptoms, distal predominant myopathy, markedly elevated creatine kinase level, and lack of peripheral neuropathy or systemic features are highly suggestive of isolated amyloid myopathy. In ATTR and AL amyloidosis, early treatment correlates with favorable outcomes. Therefore, awareness of these disorders and active screening for amyloidosis in patients with neuropathy or myopathy are crucial in detecting these patients in the everyday practice of neuromuscular medicine. Herein, we review the clinical manifestations of neuromuscular amyloidosis and provide a diagnostic approach to this disorder.
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Affiliation(s)
- Marcus V Pinto
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Federal University of Rio de Janeiro, National Amyloidosis Referral Center (CEPARM), Rio de Janeiro, Brazil
| | - P James B Dyck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Teerin Liewluck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Bolte FJ, Langenstroer C, Friebel F, Hüsing-Kabar A, Dugas M, Schmidt HH. Patient-reported outcomes on familial amyloid polyneuropathy (FAP). Orphanet J Rare Dis 2020; 15:287. [PMID: 33054844 PMCID: PMC7556910 DOI: 10.1186/s13023-020-01575-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 10/05/2020] [Indexed: 01/15/2023] Open
Abstract
Background Transthyretin familial amyloid polyneuropathy (ATTR-FAP) is a rare autosomal dominant inherited disease affecting multiple organ systems. ATTR-FAP patients’ experiences have rarely been documented. The aim of this study was to collect patient reported outcomes across different countries to assess unmet needs and challenges. An anonymous survey was conducted at the 2nd European meeting on ATTR amyloidosis in Berlin in September 2019. Survey questions captured information on demographics, clinical characteristics, diagnostic experience, quality of life, disability and ATTR-FAP management. Results A total of 38 ATTR-FAP patients from 15 different countries participated in the survey. ATTR-FAP had a substantial impact on patients’ day-to-day life, including difficulties in standing, walking, and participation in community activities. It also had negative effects on the mental health of patients. The survey highlighted several unmet needs and challenges from a patients’ perspective, including (i) a need for increased awareness and a standardized diagnostic pathway, (ii) a need for better treatment access and supportive care and (iii) a need for better information about research and clinical trials. Conclusions This global patient survey provides valuable findings to address ATTR-FAP patients’ needs and challenges in order to further the goal of patient-centered care.
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Affiliation(s)
- Fabian J Bolte
- Medizinische Klinik B (Gastroenterologie, Hepatologie, Endokrinologie, Klinische Infektiologie), Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A14, 48149, Münster, Germany.
| | - Christel Langenstroer
- Medizinische Klinik B (Gastroenterologie, Hepatologie, Endokrinologie, Klinische Infektiologie), Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A14, 48149, Münster, Germany
| | - Frauke Friebel
- Medizinische Klinik B (Gastroenterologie, Hepatologie, Endokrinologie, Klinische Infektiologie), Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A14, 48149, Münster, Germany
| | - Anna Hüsing-Kabar
- Medizinische Klinik B (Gastroenterologie, Hepatologie, Endokrinologie, Klinische Infektiologie), Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A14, 48149, Münster, Germany
| | - Martin Dugas
- Institut für Medizinische Informatik, Universitätsklinikum Münster, Münster, Germany
| | - Hartmut H Schmidt
- Medizinische Klinik B (Gastroenterologie, Hepatologie, Endokrinologie, Klinische Infektiologie), Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A14, 48149, Münster, Germany
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Presence of val30Met and val122ile mutations in a patient with hereditary amyloidosis. J Hum Genet 2020; 65:711-713. [PMID: 32269295 DOI: 10.1038/s10038-020-0749-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/03/2020] [Accepted: 03/12/2020] [Indexed: 11/08/2022]
Abstract
Amyloidosis, caused by a mutation in the transthyretin (TTR) gene, is the most common hereditary type disease. More than 120 mutations have been described, with extensive phenotypic heterogeneity. Val30Met (p.Val50Met) is the most frequent mutation, and patients exhibit polyneuropathy, possibly including cardiac, renal, gastrointestinal, and/or ocular involvement. Val122Ile (p.Val142Ile) is the mutation associated with cardiomyopathy, and few cases have been reported in Brazil. Most individuals are heterozygous for one pathogenic mutation. Herein, we report a compound heterozygote with two pathogenic mutations (Val30Met/ Val122Ile), and a family history of a deceased brother with amyloidosis, who also carried the same TTR gene mutations. The patient presented with neuropathic, cardiac, and renal impairment and a faster disease progression. Cases of the double mutation have been linked to changes in disease presentation. The concomitance of two pathogenic mutations may have contributed to more exuberant manifestations and faster disease progression.
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Pande M, Srivastava R. Molecular and clinical insights into protein misfolding and associated amyloidosis. Eur J Med Chem 2019; 184:111753. [PMID: 31622853 DOI: 10.1016/j.ejmech.2019.111753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/24/2019] [Accepted: 10/01/2019] [Indexed: 12/13/2022]
Abstract
The misfolding of normally soluble proteins causes their aggregation and deposition in the tissues which disrupts the normal structure and function of the corresponding organs. The proteins with high β-sheet contents are more prone to form amyloids as they exhibit high propensity of self-aggregation. The self aggregated misfolded proteins act as template for further aggregation that leads to formation of protofilaments and eventually amyloid fibrils. More than 30 different types of proteins are known to be associated with amyloidosis related diseases. Several aspects of the amyloidogenic behavior of proteins remain elusive. The exact reason that causes misfolding of the protein and its association into amyloid fibrils is not known. These misfolded intermediates surpass the over engaged quality control system of the cell which clears the misfolded intermediates. This promotes the self-aggregation, accumulation and deposition of these misfolded species in the form of amyloids in the different parts of the body. The amyloid deposition can be localized as in Alzheimer disease or systemic as reported in most of the amyloidosis. The amyloidosis can be of acquired type or familial. The current review aims at bringing together recent updates and comprehensive information about protein amyloidosis and associated diseases at one place.
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Affiliation(s)
- Monu Pande
- Department of Biochemistry, Institute of Medical Science, Banaras Hindu University, Varanasi, 221005, India
| | - Ragini Srivastava
- Department of Biochemistry, Institute of Medical Science, Banaras Hindu University, Varanasi, 221005, India.
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Pinto MV, Pinto LF, Dias M, Rosa RS, Mundayat R, Pedrosa RC, Waddington-Cruz M. Late-onset hereditary ATTR V30M amyloidosis with polyneuropathy: Characterization of Brazilian subjects from the THAOS registry. J Neurol Sci 2019; 403:1-6. [PMID: 31163298 DOI: 10.1016/j.jns.2019.05.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/06/2019] [Accepted: 05/27/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite growing numbers of patients diagnosed with late-onset hereditary ATTR V30M amyloidosis with polyneuropathy (ATTRv-PN), this condition remains poorly characterized in Brazil. OBJECTIVE Characterize late-onset V30M ATTRv-PN in Brazil. MATERIAL AND METHODS Demographic and clinical data at the time of enrolment for Brazilian subjects with symptomatic V30M ATTRv-PN were extracted from the ongoing, multinational, longitudinal, observational Transthyretin Amyloidosis Outcomes Survey (THAOS; cut-off date: January 30, 2017). Subjects were divided into those with symptom onset at age <50 years (EO-V30M), and at age ≥50 years (LO-V30M). RESULTS A total of 96 Val30Met patients were symptomatic. LO-V30M (n = 25, 26.0%) had a longer time to diagnosis (mean 5.1 vs. 2.8 yrs.; p = 0.006) and less frequently positive family history (40% vs. 95.8%; p < 0.0001) than EO-V30M. Clinically, subjects with LO-V30M had more imbalance (92% vs. 54.9%; p = 0.006), deep sensory loss (100% vs. 80%; p = 0.0178), electrocardiogram abnormalities (88.9% vs. 59.4; p = 0.0241), and interventricular septum hypertrophy (69.2% vs. 0%; p < 0001) and less frequently sensory dissociation (12% vs. 74%; p < 0.0001). Also, LO-V30M tended to have more severe mean Neurologic Composite Score (101 vs. 70 pts.; p = 0.1136). CONCLUSIONS LO-V30M ATTRv-PN is not unusual in Brazil, tending to be more difficult to diagnose and present with a more severe phenotype, with more large nerve fibers and cardiac involvement than EO-V30M. TRIAL REGISTRATION ClinicalTrials.gov: NCT00628745.
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Affiliation(s)
- Marcus Vinicius Pinto
- National Amyloidosis Referral Center, CEPARM, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Department of Neurology, Mayo Clinic, Rochester, MN, USA.
| | - Luiz Felipe Pinto
- National Amyloidosis Referral Center, CEPARM, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Moises Dias
- National Amyloidosis Referral Center, CEPARM, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Renata Santa Rosa
- National Amyloidosis Referral Center, CEPARM, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Roberto Coury Pedrosa
- National Amyloidosis Referral Center, CEPARM, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcia Waddington-Cruz
- National Amyloidosis Referral Center, CEPARM, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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15
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Brandão PRP, Carnelos LAA, Melo D. Amilton Barreira: a mentor who left imprints on future neurologists. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:218-219. [PMID: 30970138 DOI: 10.1590/0004-282x20190021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Affiliation(s)
| | | | - Denise Melo
- Rede Sarah de Hospitais de Reabilitação, Brasília DF, Brasil
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16
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Cruz MW, Pinto MV, Pinto LF, Gervais R, Dias M, Perez C, Mundayat R, Ong ML, Pedrosa RC, Foguel D. Baseline disease characteristics in Brazilian patients enrolled in Transthyretin Amyloidosis Outcome Survey (THAOS). ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:96-100. [PMID: 30810593 DOI: 10.1590/0004-282x20180156] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/23/2018] [Indexed: 11/22/2022]
Abstract
Transthyretin amyloidosis (ATTR) is characterized by the deposit of mutant or wild-type transthyretin that forms amyloid fibrils, which are extracellularly deposited within tissues and organs. Clinical manifestations of familial amyloid polyneuropathy vary according to the mutation, age at onset and geographical location. This study aimed to describe baseline disease characteristics of Brazilian patients with transthyretin familial amyloid polyneuropathy (ATTR-FAP) enrolled in the Transthyretin Amyloidosis Outcome Survey (THAOS). METHODS The THAOS is an international, noninterventional, longitudinal, observational, web-based registry designed to characterize ATTR. The outcome measures included demographics (age at symptom onset, gender, time from onset of symptoms to diagnosis, family history), genotype, and clinical characteristics (presence of amyloid deposit, frequency of misdiagnosis, presenting symptomatology). The analysis was conducted in a dataset from Brazilian patients (from November 2008 to January 2016). RESULTS One hundred and sixty participants (52.5% male) were included in the analysis. The majority of participants (90.6%) reported a positive family history of ATTR-FAP Median age at symptom onset was 32.5 years. Val30Met mutation was found in 91.9%. Misdiagnosis was observed in 26.6% of symptomatic patients. Over one-third (35.3%) of the misdiagnosed patients experienced a delay of more than one year before receiving a correct diagnosis. At presentation, 79.7% of the patients had motor, 87.5% sensory and 93.8% autonomic symptoms. CONCLUSION ATTR-FAP in Brazil starts early, has a strong family history and the majority has Val30Met mutation. Misdiagnosis is common and the most common presentation is of a sensorimotor and autonomic neuropathy.
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Affiliation(s)
- Márcia Waddington Cruz
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello
| | - Marcus Vinicius Pinto
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello
| | - Luiz Felipe Pinto
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello
| | - Renata Gervais
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello
| | - Moisés Dias
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello
| | - Carlos Perez
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello
| | | | | | - Roberto Coury Pedrosa
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello
| | - Débora Foguel
- Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Centro de Estudos em Paramiloidose Antônio Rodrigues de Mello
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Obici L. Becoming familiar with hereditary transthyretin amyloidosis, a treatable neuropathy. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:573-574. [DOI: 10.1590/0004-282x20180102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 08/27/2018] [Indexed: 11/21/2022]
Affiliation(s)
- Laura Obici
- Fondazione IRCCS Policlinico San Matteo, Italy
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