Association of reproductive factors and exogenous hormone use with distal sensory polyneuropathy among postmenopausal women in the United States: results from 1999 to 2004 NHANES

Postmenopausal status is a risk factor for distal sensory polyneuropathy-the most common type of peripheral neuropathy. We aimed to investigate associations between reproductive factors and history of exogenous hormone use with distal sensory polyneuropathy among postmenopausal women in the United States using data from the National Health and Nutrition Examination Survey 1999-2004, and to explore the modifying effects of ethnicity on these associations. We conducted a cross-sectional study among postmenopausal women aged ≥ 40 years. Women with a history of diabetes, stroke, cancer, cardiovascular disease, thyroid disease, liver disease, weak or failing kidneys, or amputation were excluded. Distal sensory polyneuropathy was measured using a 10-g monofilament test, and a questionnaire was used to collect data on reproductive history. Multivariable survey logistic regression was used to test the association between reproductive history variables and distal sensory polyneuropathy. In total, 1144 postmenopausal women aged ≥ 40 years were included. The adjusted odds ratios were 8.13 [95% confidence interval (CI) 1.24-53.28] and 3.18 (95% CI 1.32-7.68) for age at menarche < 11 years and time since menopause > 20 years, respectively, which were positively associated with distal sensory polyneuropathy; adjusted odds ratios were 0.45 for the history of breastfeeding (95% CI 0.21-0.99) and 0.41 for exogenous hormone use (95% CI 0.19-0.87) were negatively associated. Subgroup analysis revealed ethnicity-based heterogeneity in these associations. Age at menarche, time since menopause, breastfeeding, and exogenous hormone use were associated with distal sensory polyneuropathy. Ethnicity significantly modified these associations.

Syncope with autonomic dysfunction assessed with the Thai-COMPASS 31 questionnaire

Introduction

Alteration of autonomic function is the main pathophysiology of most types of syncope, including syncope due to orthostatic hypotension and neurally mediated syncope or reflex syncope. The aim of this study was to investigate the difference in autonomic dysfunction assessed between each type of syncope and to evaluate the association between the severity of autonomic dysfunction and the recurrence of syncope.

Methodology

Three hundred and six participants, including 195 syncope and 109 healthy control participants, were recruited to this retrospective cohort study. Autonomic function was initially assessed by the Thai version of the Composite Autonomic Symptom Score 31 (COMPASS 31), a self-administered questionnaire.

Result

According to one hundred and ninety-five syncope participants, twenty-three participants had syncope due to orthostatic hypotension, 61 had reflex syncope, 79 had presyncope, and 32 had unclassified syncope. Participants in the syncope due to orthostatic hypotension and reflex syncope groups had significantly higher COMPASS 31 scores than the control and presyncope groups, of which the syncope due to orthostatic hypotension group had the highest score. The cutoff score of 32.9 for COMPASS 31 had a sensitivity of 50.0% and a specificity of 81.9% to predict the recurrence of syncope.

Conclusion

The degree of autonomic dysfunction, which was assessed by COMPASS 31, could vary depending on the syncope type. The COMPASS 31, which is an easy-to-use self-administered questionnaire utilized for the assessment of autonomic symptoms and function, was a helpful tool for classifying some types of syncope and predicting the recurrence of syncope, which could lead to appropriate further management.

Association Between Breastfeeding and Reduced Distal Sensory Polyneuropathy in Postmenopausal Women Aged 40-70 Years: Analysis of Data from the 1999-2004 National Health and Nutrition Examination Survey

Background: Distal sensory polyneuropathy (DSP) is a common peripheral neuropathy subtype. We aimed to determine the association between breastfeeding and DSP among postmenopausal women aged 40-70 years, and the effect modification of obesity on this association. Methods: A cross-sectional study was conducted using data from the National Health and Nutrition Examination Survey 1999-2004. Postmenopausal women aged 40-70 years were included. Women with diabetes, stroke, cancer, cardiovascular disease, thyroid disease, liver disease, weak/failing kidneys, or amputation were excluded. Binary logistic regression was used to analyze the association between breastfeeding and DSP. Results: Among 798 participants, 386 (44.30%) reported breastfeeding history and 51 (5.29%) were defined as having DSP using the monofilament test. A significant inverse association was observed between breastfeeding and DSP (odds ratio [OR] = 0.29; 95% confidence interval [CI]: 0.11-0.79; p = 0.017) after adjusting for other confounding variables. In subgroup analysis, this adjusted association was observed only in the obese group (OR = 0.21; 95% CI: 0.06-0.73, p = 0.013). Conclusions: Breastfeeding was found to have potential benefits in the presence of DSP in postmenopausal women aged 40-70 years, and obesity modified the association between breastfeeding and DSP. Promoting breastfeeding may reduce the burden of peripheral neuropathy in middle-aged postmenopausal women.

Sural-sparing pattern: A study against electrodiagnostic subtypes of Guillain–Barre syndrome

•

This study investigated sural-sparing in GBS patients who underwent extensive sensory NCS protocol.

•

Sural-sparing was less obvious in axonal than demyelinating GBS based on the number of affected upper-limb SNAPs.

•

Extended sensory NCS (bilateral or serial) is worth detecting sural-sparing as a supportive EDX feature of GBS.

Objective

To study sural-sparing pattern in Guillain–Barre syndrome (GBS) and compare it among GBS’s electrodiagnostic subtypes, classified by two recent criteria.

Methods

This study retrospectively reviewed clinical data and electrodiagnostic studies (EDXs) of 88 GBS patients diagnosed in a tertiary care hospital (2010–2019).

Results

Overall, 79/88 (89.8%) and 36/45 (80%) patients had bilateral sensory nerve conduction studies (NCS) in the first EDX and follow-up EDX, respectively. Sural-sparing occurred in all subtypes (50% overall occurrence rate), most commonly in demyelination. There was no statistically significant difference in sural-sparing occurrence rates between demyelinating and axonal GBS; however, sural-sparing in axonal GBS tended to show a lower number of abnormal upper-limb sensory nerve action potentials (SNAPs) than demyelinating GBS. Shifting between sural-sparing and no sural-sparing occurred in approximately-one-fourth of patients receiving serial studies. Follow-up EDX additionally discovered 20% of all sural-sparing. Unilateral EDX could have omitted up to 30% of sural-sparing.

Conclusions

Sural-sparing is less obviously manifested in axonal than demyelinating GBS, with respect to the number of affected upper-limb SNAPs. Extended sensory NCS is worth in detecting sural-sparing as a supportive electrodiagnostic GBS feature.

Significance

This report showed one different character of sural-sparing (number of affected upper-limb SNAPs) between demyelinating and axonal GBS.

Dengue infection triggered immune mediated necrotizing myopathy in children: a case report and literature review

BACKGROUND

Immune-mediated necrotizing myopathy (IMNM) is a subgroup of idiopathic inflammatory myopathies manifesting with progressive weakness, elevated serum creatine kinase (CK) levels, and necrotizing myopathic features on muscle biopsy. There is a paucity of data on the clinical presentation of IMNM in children. We report a paediatric patient who developed anti-3-hydroxy-3-methylglutaryl-CoA reductase (anti-HMGCR)-positive necrotizing myopathy after recent dengue infection.

CASE PRESENTATION

A previously healthy 9-year-old boy presented with acute proximal muscle weakness after recovery from dengue infection. Five days after the fever subsided, he could not stand from a squatting position. He denied having skin rash, arthritis, or other systemic features. He had marked elevation of CK level of 30,833 mg/dL and was put on steroid therapy. The patient initially responded to oral prednisolone, however the weakness persisted and muscle enzymes increased as steroids were decreased. He was then referred to our hospital for further assessment. Subsequent investigation revealed anti-HMGCR positivity along with specific histopathological findings consistent with IMNM. The patient was treated with six cycles of intravenous immunoglobulin (IVIG) monthly, then followed by a gradual taper of prednisolone and oral methotrexate weekly with complete recovery in motor power.

CONCLUSIONS

Our report presents a child with clinical manifestations of IMNM which can be categorized as acute onset of muscle weakness following dengue infection. Two key points supporting a diagnosis in this case are clinical response after immunosuppressive therapy and absence of rashes found in juvenile dermatomyositis.

Thyrotoxic hypokalemic periodic paralysis and COVID-19 infection

Various conditions causing weakness associated with coronavirus disease 2019 (COVID-19) infection have been described, including cerebrovascular diseases, acute myelitis, Guillain-Barré syndrome, myasthenia gravis, critical illness myopathy and neuropathy, myositis, and rhabdomyolysis. We report an adult man presenting with an unusual etiology of weakness after a COVID-19 infection. Thyrotoxic hypokalemic periodic paralysis (THPP) was diagnosed from the presence of Graves' disease and hypokalemia because of intra-cellular potassium shifting. His weakness and hypokalemia responded well to potassium supplements and a non-selective b-blocker, whereas his thyrotoxicosis was initially controlled by an anti-thyroid medication and subsequently with radioactive iodine therapy. He was also treated as having mild COVID-19 based on his normal chest X-ray and oxygenation level. This is the first report showing an association between COVID-19 infection and a paralysis attack of THPP. Physicians should be alerted about this unusual cause of weakness, particularly in Asian patients.

Ala97Ser transthyretin amyloidosis-associated polyneuropathy, clinical and neurophysiological profiles in a Thai cohort

Background

Ala97Ser transthyretin amyloidosis-associated polyneuropathy (ATTRA97S-PN) is a rare form of inherited polyneuropathy, usually manifesting with late-onset (> 50) progressive polyneuropathy. This mutation is mostly prevalent in Taiwanese and Han-Chinese individuals. The aim of this study was to describe the clinical and comprehensive neurophysiological profiles of ATTRA97S-PN in Thai patients.

Methods

The clinical profiles and serial neurophysiologic studies (nerve conduction study (NCS), quantitative sensory test (QST), and comprehensive autonomic function test (AFT)) of symptomatic ATTRA97S-PN patients who had been followed-up at King Chulalongkorn Memorial Hospital during 2010–2020 were retrospectively reviewed.

Results

Nine symptomatic patients (55.6 % were male) from four unrelated families were included. All were Thais of mixed Thai Chinese descent. The mean age of onset was 48.3 (32–60) years. The mean age at diagnosis was 54.8 (33–66) years. Three patients developed early-onset (< 40y) polyneuropathy. The mean Neuropathy Impairment Score was 41.33 (10–92) at diagnosis. Sensory (9/9) and autonomic (9/9) neuropathies were more frequent than motor neuropathy (5/9), which appeared in the late stage of disease. Hypoesthesia in the feet, and gastrointestinal autonomic symptoms were frequently reported as the initial symptoms. The course of neuropathy progressed over years to decades. The worsening of neuropathy tended to progress faster once motor nerves were affected in both clinical and neurophysiological aspects. Concurrent cardiac amyloidosis was found in 6/9 patients. NCS showed length-dependent sensorimotor axonal polyneuropathy in 5/9 patients, and median neuropathy at the wrist (mostly bilateral) in 7/9 patients. QST showed abnormalities in the vibratory detection threshold, the cold detection threshold and the heat pain sensation in 8/9, 8/9 and 7/7 tested patients, respectively. AFT results were abnormal in all. The mean composite autonomic severity score was 5 (3–9).

Conclusions

This clinical study is the first of ATTRA97S-PN in Thai patients. The mixed polyneuropathy-cardiopathy phenotype was the most common manifestation. In this cohort, the age of onset was lower, and the course of neuropathy was relatively longer, than that in previous studies. Some patients may develop early-onset polyneuropathy. This mutation has not yet been documented in any population other than Han Chinese-related populations, probably suggesting a founder effect. Further studies are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02243-3.

Mid-palm recording technique, a new electrodiagnostic approach in Martin-Gruber anastomosis

•

This report describes a new electrophysiological pattern of MGA.

•

The mid-palm recording provides a broader view in terms of innervation of MGA.

•

This technique is not complicated and can be added into the investigation of MGA.

Introduction

Median and ulnar motor nerve conduction study recording from median-innervated 2nd lumbrical and ulnar-innervated 1st palmar and 2nd dorsal interossei is designated in electrodiagnostic evaluation of carpal tunnel syndrome. In this technique, both responses are recorded by the same surface recording electrode placing over their shared motor point in mid-palm. To the best of our knowledge, this technique has never been utilized in demonstration of Martin-Gruber anastomosis.

Case reports

By applying this technique to the conventional CMAP comparison method, the authors accordingly demonstrated Martin-Gruber anastomosis in four cases. Three presented with focal mononeuropathies of the upper limbs, including a severe carpal tunnel syndrome, a mild to moderate carpal tunnel syndrome, and an ulnar neuropathy. One was a normal individual.

Significance

This report described a new electrophysiological pattern of MGA. Adding the mid-palm recording to conventional CMAP comparison method provides a broader view in terms of innervation of MGA. This technique is not complicated and can be added to the electrophysiological investigation for complete studying of the innervated muscles in MGA.

Efficacy of exogenous pyruvate in TremblerJ mouse model of Charcot-Marie-Tooth neuropathy

INTRODUCTION

Classic Charcot-Marie-Tooth (CMT) neuropathies including those with Schwann cell genetic defects exhibit a length-dependent process affecting the distal axon. Energy deprivation in the distal axon has been the proposed mechanism accounting for length-dependent distal axonal degeneration. We hypothesized that pyruvate, an intermediate glycolytic product, could restore nerve function, supplying lost energy to the distal axon.

METHODS

To test this possibility, we supplied pyruvate to the drinking water of the Trembler-J (TrJ ) mouse and assessed efficacy based on histology, electrophysiology, and functional outcomes. Pyruvate outcomes were compared with untreated TrJ controls alone or adeno-associated virus mediated NT-3 gene therapy (AAV1.NT-3)/pyruvate combinatorial approach.

RESULTS

Pyruvate supplementation resulted increased myelinated fiber (MF) densities and myelin thickness in sciatic nerves. Combining pyruvate with proven efficacy from AAV1.tMCK.NT-3 gene therapy provided additional benefits showing improved compound muscle action potential amplitudes and nerve conduction velocities compared to pyruvate alone cohort. The end point motor performance of both the pyruvate and the combinatorial therapy cohorts was better than untreated TrJ controls. In a unilateral sciatic nerve crush paradigm, pyruvate supplementation improved myelin-based outcomes in both regenerating and the contralateral uncrushed nerves.

CONCLUSIONS

This proof of principle study demonstrates that exogenous pyruvate alone or as adjunct therapy in TrJ may have clinical implications and is a candidate therapy for CMT neuropathies without known treatment.

Impaired regeneration in calpain-3 null muscle is associated with perturbations in mTORC1 signaling and defective mitochondrial biogenesis

Background

Previous studies in patients with limb-girdle muscular dystrophy type 2A (LGMD2A) have suggested that calpain-3 (CAPN3) mutations result in aberrant regeneration in muscle.

Methods

To gain insight into pathogenesis of aberrant muscle regeneration in LGMD2A, we used a paradigm of cardiotoxin (CTX)-induced cycles of muscle necrosis and regeneration in the CAPN3-KO mice to simulate the early features of the dystrophic process in LGMD2A. The temporal evolution of the regeneration process was followed by assessing the oxidative state, size, and the number of metabolic fiber types at 4 and 12 weeks after last CTX injection. Muscles isolated at these time points were further investigated for the key regulators of the pathways involved in various cellular processes such as protein synthesis, cellular energy status, metabolism, and cell stress to include Akt/mTORC1 signaling, mitochondrial biogenesis, and AMPK signaling. TGF-β and microRNA (miR-1, miR-206, miR-133a) regulation were also assessed. Additional studies included in vitro assays for quantifying fusion index of myoblasts from CAPN3-KO mice and development of an in vivo gene therapy paradigm for restoration of impaired regeneration using the adeno-associated virus vector carrying CAPN3 gene in the muscle.

Results

At 4 and 12 weeks after last CTX injection, we found impaired regeneration in CAPN3-KO muscle characterized by excessive numbers of small lobulated fibers belonging to oxidative metabolic type (slow twitch) and increased connective tissue. TGF-β transcription levels in the regenerating CAPN3-KO muscles were significantly increased along with microRNA dysregulation compared to wild type (WT), and the attenuated radial growth of muscle fibers was accompanied by perturbed Akt/mTORC1 signaling, uncoupled from protein synthesis, through activation of AMPK pathway, thought to be triggered by energy shortage in the CAPN3-KO muscle. This was associated with failure to increase mitochondria content, PGC-1α, and ATP5D transcripts in the regenerating CAPN3-KO muscles compared to WT. In vitro studies showed defective myotube fusion in CAPN3-KO myoblast cultures. Replacement of CAPN3 by gene therapy in vivo increased the fiber size and decreased the number of small oxidative fibers.

Conclusion

Our findings provide insights into understanding of the impaired radial growth phase of regeneration in calpainopathy.

Electronic supplementary material

The online version of this article (10.1186/s13395-017-0146-6) contains supplementary material, which is available to authorized users.

A novel p.T139M mutation in HSPB1 highlighting the phenotypic spectrum in a family

INTRODUCTION

Mutations in the HSPB1 gene encoding the small heat shock protein B1 are associated with an autosomal dominant, axonal form of Charcot-Marie-Tooth disease 2F (CMT2F) and distal hereditary motor neuropathy. Recently, distal myopathy had been described in a patient carrying HSPB1 mutation adding to the complexity of phenotypes resulting from HSPB1 mutations.

METHODS

Five patients in a family with concerns of hereditary neuropathy were included. Detailed clinical examinations, including assessments of motor and sensory function, and electrophysiological data were obtained. Genetic analysis was requested through a commercial laboratory. In vitro studies were carried out to assess the pathogenicity of the novel mutation found in this family studies.

RESULTS

All patients carried a novel mutation, c.146 C>T (p.T139M), substitution in the α-crystallin domain of HSPB1 causing a clinical phenotype with hyperreflexia and intrafamilial variability, from muscle cramps as the only presenting symptom to a classic CMT phenotype. In vitro studies showed that cells expressing HSPB1-T139M displayed decreased cell viability with increased expression of apoptosis markers. Moreover, overexpression of the mutant, not the wild-type HSPB1, caused formation of congophilic aggregates.

CONCLUSIONS

In vitro findings strongly support the pathogenicity of this novel mutation. We propose that Congo red histochemical stain may serve as a simple screening tool for investigating if the aggregates in mutant cells have misfolded β-pleated sheet secondary structures.

Fulminant respiratory muscle paralysis, an expanding clinical spectrum of mitochondrial A3243G tRNALeu mutation

Mitochondrial disease is a group of rare disorders, caused by mitochondrial dysfunction. They are usually the result of mutations of either mitochondrial DNA or nuclear DNA. A3243G transition in the tRNALeu is one the most frequent mutations of the mitochondrial DNA. Phenotypic expression of this mutation varies. The most well-recognized phenotype is Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome. Isolated myopathy with respiratory muscle weakness in this mutation has been rarely documented. The authors reported a 20-year-old Asian female presenting with a fulminant hypoventilatory respiratory failure with mild weakness of the limbs. Electrophysiologic study showed evidences of myopathy. Restrictive physiology of the lungs was demonstrated by pulmonary function test. Subsarcolemmal accumulation of mitochondria was demonstrated by Gomori trichrome and succinate dehydrogenase stains. Genetic study revealed the A3243G mutation in mitochondrial DNA in peripheral blood Isolated mitochondrial myopathy severely affecting respiratory muscles may be considered as an uncommon clinical spectrum of A3243G mitochondrial disease.