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Bunting E, Cooper R, Seral M, Manji H, Rossor A, Reilly MM, Lunn MP, Bennett D, Hadden R, Carr AS. 099 High relapse rate with steroid monotherapy in non-systemic vasculitic neuropathy. J Neurol Neurosurg Psychiatry 2022. [DOI: 10.1136/jnnp-2022-abn.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
IntroductionHistorically, single tissue vasculitis has been managed with steroid monotherapy. Recent data from large longitudinal databases on systemic vasculitis suggest Non-Systemic Vasculitic Neuropathy (NSVN) has higher rates of relapse, recommending that more aggressive immunotherapy is employed.AimTo investigate the relapse rate in NSVN in response to steroid monotherapy.MethodsA retrospective case note review of clinically and/or pathologically defined cases of (Systemic Vasculitic Neuropathy) SVN and NSVN in two London specialist peripheral nerve centres, between 2005- 2012 and 2015 - 2019.Results32 cases of SVN and 34 cases of NSVN were identified. In each group 14 individuals were treated first-line with steroid monotherapy, and 8 with cyclophosphamide. 8 SVN and 9 NSVN cases received steroids plus azathioprine. 15/32 SVN and 13/34 NSVN relapsed after first-line therapy (10/14 and 9/14 on steroid monotherapy, 3/8 and 3/9 on steroids and azathioprine, 2/8 and 1/8 on cyclophosphamide). 10 individuals stabilised with the addition of azathioprine, 13 with cyclophosphamide and 4 with Rituximab.ConclusionThis representative case series suggests that steroid monotherapy is inadequate in the treatment of NSVN and supports an approach akin to that recommended in SVN, even if nerve is the only tissue clinically involved.e.bunting@nhs.net
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Bus SRM, Zambreanu L, Abbas A, Rajabally YA, Hadden RDM, de Haan RJ, de Borgie CAJM, Lunn MP, van Schaik IN, Eftimov F. Intravenous immunoglobulin and intravenous methylprednisolone as optimal induction treatment in chronic inflammatory demyelinating polyradiculoneuropathy: protocol of an international, randomised, double-blind, placebo-controlled trial (OPTIC). Trials 2021; 22:155. [PMID: 33608058 PMCID: PMC7894234 DOI: 10.1186/s13063-021-05083-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/29/2021] [Indexed: 11/28/2022] Open
Abstract
Background International guidelines recommend either intravenous immunoglobulin (IVIg) or corticosteroids as first-line treatment for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). IVIg treatment usually leads to rapid improvement and is generally safe, but does not seem to lead to long-term remissions. Corticosteroids act more slowly and are associated with more side effects, but may induce long-term remissions. The hypothesis of this study is that combined IVIg and corticosteroid induction treatment will lead to more frequent long-term remissions than IVIg treatment alone. Methods An international, randomised, double-blind, placebo-controlled trial, in adults with ‘probable’ or ‘definite’ CIDP according to the EFNS/PNS 2010 criteria. Three groups of patients are included: (1) treatment naïve, (2) known CIDP patients with a relapse after > 1 year without treatment, and (3) patients with CIDP who improved within 3 months after a single course of IVIg, who subsequently deteriorate at any interval without having received additional treatment. Patients are randomised to receive 7 courses of IVIg and 1000 mg intravenous methylprednisolone (IVMP) (in sodium chloride 0.9%) or IVIg and placebo (sodium chloride 0.9%), every 3 weeks for 18 weeks. IVIg treatment consists of a loading dose of 2 g/kg (over 3–5 days) followed by 6 courses of IVIg 1/g/kg (over 1–2 days). The primary outcome is remission at 1 year, defined as improvement in disability from baseline, sustained between week 18 and week 52 without further treatment. Secondary outcomes include changes in disability, impairment, pain, fatigue, quality of life, care use and costs and (long-term) safety. Discussion In case of superiority of the combined treatment, patients will experience the advantages of two proven efficacious treatments, namely rapid improvement due to IVIg and long-term remission due to corticosteroids. Long-term remission would reduce the need for maintenance IVIg treatment and may decrease health care costs. Additionally, we expect that the combined treatment leads to a higher proportion of patients with improvement as some patients who do not respond to IVIg will respond to corticosteroids. Risks of short and long-term additional adverse events of the combined treatment need to be assessed. Trial registration ISRCTN registry ISRCTN15893334. Prospectively registered on 12 February 2018.
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Affiliation(s)
- S R M Bus
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - L Zambreanu
- Department of Neurology, National Hospital for Neurology and Neurosurgery, Centre for Neuromuscular Disease, London, UK
| | - A Abbas
- Department of Neurology, University Hospitals of Birmingham, Regional Neuromuscular Service, Birmingham, UK
| | - Y A Rajabally
- Department of Neurology, University Hospitals of Birmingham, Regional Neuromuscular Service, Birmingham, UK
| | - R D M Hadden
- Department of Neurology, King's College Hospital, London, UK
| | - R J de Haan
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C A J M de Borgie
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M P Lunn
- Department of Neurology, National Hospital for Neurology and Neurosurgery, Centre for Neuromuscular Disease, London, UK
| | - I N van Schaik
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Spaarne Gasthuis, Haarlem, the Netherlands
| | - F Eftimov
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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Keddie S, Ziff O, Chou MKL, Taylor RL, Heslegrave A, Garr E, Lakdawala N, Church A, Ludwig D, Manson J, Scully M, Nastouli E, Chapman MD, Hart M, Lunn MP. Laboratory biomarkers associated with COVID-19 severity and management. Clin Immunol 2020; 221:108614. [PMID: 33153974 PMCID: PMC7581344 DOI: 10.1016/j.clim.2020.108614] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/14/2020] [Accepted: 10/20/2020] [Indexed: 01/08/2023]
Abstract
The heterogeneous disease course of COVID-19 is unpredictable, ranging from mild self-limiting symptoms to cytokine storms, acute respiratory distress syndrome (ARDS), multi-organ failure and death. Identification of high-risk cases will enable appropriate intervention and escalation. This study investigates the routine laboratory tests and cytokines implicated in COVID-19 for their potential application as biomarkers of disease severity, respiratory failure and need of higher-level care. From analysis of 203 samples, CRP, IL-6, IL-10 and LDH were most strongly correlated with the WHO ordinal scale of illness severity, the fraction of inspired oxygen delivery, radiological evidence of ARDS and level of respiratory support (p ≤ 0.001). IL-6 levels of ≥3.27 pg/ml provide a sensitivity of 0.87 and specificity of 0.64 for a requirement of ventilation, and a CRP of ≥37 mg/l of 0.91 and 0.66. Reliable stratification of high-risk cases has significant implications on patient triage, resource management and potentially the initiation of novel therapies in severe patients.
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Affiliation(s)
- S Keddie
- Neuroimmunology and CSF laboratory, University College London Hospitals NHS Trust National Hospital of Neurology and Neurosurgery, Queen Square, London, UK.
| | - O Ziff
- Neuroimmunology and CSF laboratory, University College London Hospitals NHS Trust National Hospital of Neurology and Neurosurgery, Queen Square, London, UK
| | - M K L Chou
- Neuroimmunology and CSF laboratory, University College London Hospitals NHS Trust National Hospital of Neurology and Neurosurgery, Queen Square, London, UK
| | - R L Taylor
- Neuroimmunology and CSF laboratory, University College London Hospitals NHS Trust National Hospital of Neurology and Neurosurgery, Queen Square, London, UK
| | - A Heslegrave
- UK Dementia Research Institute, University College London, London, UK
| | - E Garr
- Neuroimmunology and CSF laboratory, University College London Hospitals NHS Trust National Hospital of Neurology and Neurosurgery, Queen Square, London, UK
| | - N Lakdawala
- Neuroimmunology and CSF laboratory, University College London Hospitals NHS Trust National Hospital of Neurology and Neurosurgery, Queen Square, London, UK
| | - A Church
- Neuroimmunology and CSF laboratory, University College London Hospitals NHS Trust National Hospital of Neurology and Neurosurgery, Queen Square, London, UK
| | - D Ludwig
- Department of Rheumatology, University College London Hospitals NHS Trust, London, UK
| | - J Manson
- Department of Rheumatology, University College London Hospitals NHS Trust, London, UK
| | - M Scully
- Department of Haematology, University College London Hospitals NHS Foundation Trust and Cardiometabolic Programme-NIHR UCLH/UC BRC, London, UK
| | - E Nastouli
- Infection control department, University College London Hospitals NHS Trust, London, UK
| | - M D Chapman
- Neuroimmunology and CSF laboratory, University College London Hospitals NHS Trust National Hospital of Neurology and Neurosurgery, Queen Square, London, UK
| | - M Hart
- Neuroimmunology and CSF laboratory, University College London Hospitals NHS Trust National Hospital of Neurology and Neurosurgery, Queen Square, London, UK
| | - M P Lunn
- Neuroimmunology and CSF laboratory, University College London Hospitals NHS Trust National Hospital of Neurology and Neurosurgery, Queen Square, London, UK
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Kinsella JA, Irani SR, Hollingsworth R, O'Shaughnessy D, Kane P, Foster M, Schott JM, Lunn MP. Use of intravenous immunoglobulin for the treatment of autoimmune encephalitis: audit of the NHS experience. JRSM Open 2018; 9:2054270418793021. [PMID: 30202534 PMCID: PMC6122256 DOI: 10.1177/2054270418793021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Objectives The treatments of limbic and other autoimmune encephalitis include
immunosuppression, symptomatic treatment, and in the case of paraneoplastic
syndromes, appropriate therapy for underlying neoplasms. When immunotherapy
is considered, intravenous immunoglobulin is one option for treatment,
either alone or in combination with corticosteroids. To date, however,
evidence for the use of intravenous immunoglobulin in this context comes
from case series/expert reviews as no controlled trials have been performed.
We aimed to analyse the NHS England Database of intravenous immunoglobulin
usage, which was designed to log use and guide procurement, to explore usage
and therapeutic effect of intravenous immunoglobulin in autoimmune
encephalitis in England. Design We conducted a retrospective audit and review of the NHS England Database on
intravenous immunoglobulin use. Setting NHS England Database of intravenous immunoglobulin use which covers secondary
and tertiary care prescribing and use of intravenous immunoglobulin for all
patients in hospitals in England. Participants Hospital in-patients with confirmed or suspected autoimmune/limbic
encephalitis between September 2010 and January 2017. Results A total of 625 patients who were 18 years of age or older were treated with
intravenous immunoglobulin for autoimmune encephalitis, of whom 398 were
determined as having 'highly likely' or 'definite' autoimmune/limbic
encephalitis. Ninety-six percent were treated with a single course of
intravenous immunoglobulin. The availability and accuracy of reporting of
outcomes was very poor, with complete data only available in 27% of all
cases. Conclusions This is the first review of data from this unique national database. Whilst
there was evidence for clinical improvement in many cases of patients
treated with intravenous immunoglobulin, the quality of outcome data was
generally inadequate. Methods to improve quality, accuracy and completeness
of reporting are crucial to maximise the potential value of this resource as
an auditing tool.
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Affiliation(s)
- J A Kinsella
- Dementia Research Centre, UCL Institute of Neurology, London WC1N 3BG, UK.,Department of Neurology, St. Vincent's University Hospital, University College Dublin, Dublin 4, Ireland
| | - S R Irani
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - R Hollingsworth
- Medical Data Solutions and Services (MDSAS), Manchester M12 4JD, UK
| | - D O'Shaughnessy
- Medical Data Solutions and Services (MDSAS), Manchester M12 4JD, UK
| | - P Kane
- Medical Data Solutions and Services (MDSAS), Manchester M12 4JD, UK
| | - M Foster
- Medical Data Solutions and Services (MDSAS), Manchester M12 4JD, UK
| | - J M Schott
- Dementia Research Centre, UCL Institute of Neurology, London WC1N 3BG, UK
| | - M P Lunn
- MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology, London WC1N 3BG, UK
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Keddie S, Crisp SJ, Blackaby J, Cox A, Coles A, Hart M, Church AJ, Vincent A, Zandi M, Lunn MP. Plasma cell depletion with bortezomib in the treatment of refractory N
-methyl-d
-aspartate (NMDA) receptor antibody encephalitis. Rational developments in neuroimmunological treatment. Eur J Neurol 2018; 25:1384-1388. [DOI: 10.1111/ene.13759] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/19/2018] [Indexed: 11/27/2022]
Affiliation(s)
- S. Keddie
- MRC Centre for Neuromuscular Disease; National Hospital for Neurology and Neurosurgery and Department of Molecular Neuroscience; UCL Institute of Neurology; London UK
| | - S. J. Crisp
- MRC Centre for Neuromuscular Disease; National Hospital for Neurology and Neurosurgery and Department of Molecular Neuroscience; UCL Institute of Neurology; London UK
- Department of Clinical Neurosciences; Addenbrooke's Hospital; Cambridge UK
| | - J. Blackaby
- Department of Clinical Neurosciences; Addenbrooke's Hospital; Cambridge UK
| | - A. Cox
- Department of Clinical Neurosciences; Addenbrooke's Hospital; Cambridge UK
| | - A. Coles
- Department of Clinical Neurosciences; Addenbrooke's Hospital; Cambridge UK
| | - M. Hart
- Department of Neuroinflammation; National Hospital for Neurology and Neurosurgery; UCL Institute of Neurology; London UK
- Neuroimmunology and CSF Laboratory; Institute of Neurology; National Hospital for Neurology and Neurosurgery; University College London NHS Foundation Trust; London UK
| | - A. J. Church
- Neuroimmunology and CSF Laboratory; Institute of Neurology; National Hospital for Neurology and Neurosurgery; University College London NHS Foundation Trust; London UK
| | - A. Vincent
- Nuffield Department of Clinical Neurosciences; John Radcliffe Hospital; Oxford UK
| | - M. Zandi
- MRC Centre for Neuromuscular Disease; National Hospital for Neurology and Neurosurgery and Department of Molecular Neuroscience; UCL Institute of Neurology; London UK
- Department of Clinical Neurosciences; Addenbrooke's Hospital; Cambridge UK
| | - M. P. Lunn
- MRC Centre for Neuromuscular Disease; National Hospital for Neurology and Neurosurgery and Department of Molecular Neuroscience; UCL Institute of Neurology; London UK
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6
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Spillane J, Englezou C, Sarri-Gonzalez S, Rossor A, Lunn MP, Manji H, Reilly MM, Carr AS. PO207 Thromboembolic risk in inflammatory neuromuscular disease patients on long-term ivig. J Neurol Neurosurg Psychiatry 2017. [DOI: 10.1136/jnnp-2017-abn.228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hodkinson JP, Lucas M, Lee M, Harrison M, Lunn MP, Chapel H. Therapeutic immunoglobulin should be dosed by clinical outcome rather than by body weight in obese patients. Clin Exp Immunol 2015; 181:179-87. [PMID: 25731216 DOI: 10.1111/cei.12616] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2015] [Indexed: 01/13/2023] Open
Abstract
There are currently no data to support the suggestion that the dose of therapeutic immunoglobulin (Ig) should be capped in obese patients for pharmacokinetic (PK), safety and economic reasons. We compared IgG trough levels, increment and efficiency in matched pairs of obese and lean patients receiving either replacement or immunomodulatory immunoglobulin therapy. Thirty-one obese patients were matched with a clinically equivalent lean patient across a range of indications, including primary antibody deficiency or autoimmune peripheral neuropathy. Comprehensive matching was carried out using ongoing research databases at two centres in which the dose of Ig was based on clinical outcome, whether infection prevention or documented clinical neurological stability. The IgG trough or steady state levels, IgG increments and Ig efficiencies at times of clinical stability were compared between the obese and lean cohorts and within the matched pairs. This study shows that, at a population level, obese patients achieved a higher trough and increment (but not efficiency) for a given weight-adjusted dose compared with the lean patients. However at an individual patient level there were significant exceptions to this correlation, and upon sub-group analysis no significant difference was found between obese and lean patients receiving replacement therapy. Across all dose regimens a high body mass index (BMI) cannot be used to predict reliably the patients in whom dose restriction is clinically appropriate.
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Affiliation(s)
| | - M Lucas
- Primary Immunodeficiency Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M Lee
- Department of Biostatistics, University of California, Los Angeles, CA, USA
| | - M Harrison
- National Hospital for Neurology and Neurosurgery, London, UK
| | - M P Lunn
- National Hospital for Neurology and Neurosurgery, London, UK
| | - H Chapel
- Primary Immunodeficiency Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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8
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Healy EG, Phadke R, Kidd M, Reilly MM, Lunn MP. Clinical, neuropathological and radiological evidence for a rare complication of rituximab therapy. Neuromuscul Disord 2015; 25:589-92. [PMID: 25958339 DOI: 10.1016/j.nmd.2015.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/05/2015] [Accepted: 04/07/2015] [Indexed: 11/18/2022]
Abstract
We report a rare case of myofasciitis and meningitis with deafness caused by systemic enterovirus infection in the setting of hypogammaglobulinaemia induced by rituximab. Whilst effective and generally safe, anti- CD 20 antibody therapy is increasingly recognised to result in unusual infectious complications to be considered in a treated patient presenting with neurological symptoms. These cases may pose diagnostic difficulties and can have atypical presentations. We present this rare complication of rituximab therapy, with histopathological confirmation of myofasciitis. In the older literature, enterovirus associated myofasciitis may have erroneously been termed dermatomyositis and we review the literature to demonstrate this important nosological point.
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Affiliation(s)
- E G Healy
- Department of Molecular Neurosciences, UCL Institute of Neurology, MRC Centre for Neuromuscular Diseases, London, UK
| | - R Phadke
- Division of Neuropathology, National Hospital for Neurology and Neurosurgery, London, UK
| | - M Kidd
- Department of Virology, University College London Hospitals NHS Foundation Trust, London, UK
| | - M M Reilly
- Department of Molecular Neurosciences, UCL Institute of Neurology, MRC Centre for Neuromuscular Diseases, London, UK; Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - M P Lunn
- Department of Molecular Neurosciences, UCL Institute of Neurology, MRC Centre for Neuromuscular Diseases, London, UK; Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK.
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10
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Keshavan A, Gandhi S, Lunn MP, Reilly MM. ELECTROLYTE IMBALANCE TRIGGERING RELAPSE OF INFLAMMATORY NEUROPATHY. J Neurol Neurosurg Psychiatry 2013. [DOI: 10.1136/jnnp-2013-306573.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Arthur-Farraj P, Murphy S, Laura M, Lunn MP, Manji H, Blake J, Ramdharry G, Fox Z, Reilly M. HAND WEAKNESS IN CHARCOT-MARIE-TOOTH DISEASE 1X. J Neurol Neurosurg Psychiatry 2012. [DOI: 10.1136/jnnp-2012-304200a.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Evans M, Lunn MP, Steidel K, Stam J, Day JL, Manji H. 026 Universidade Catholica de Mozambique (UCM), Beira: the second medical school in Mozambique. J Neurol Neurosurg Psychiatry 2012. [DOI: 10.1136/jnnp-2011-301993.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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13
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Michell AW, Laura M, Blake J, Lunn MP, Cox A, Gibbons VS, Davis MB, Wood NW, Manji H, Houlden H, Murray NMF, Reilly MM. GJB1 gene mutations in suspected inflammatory demyelinating neuropathies not responding to treatment. J Neurol Neurosurg Psychiatry 2009; 80:699-700. [PMID: 19448103 DOI: 10.1136/jnnp.2008.150557] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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14
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Lunn MP, Léger JM, Merkies IS, Van den Bergh P, van Schaik IN. 151st ENMC International Workshop: Inflammatory Neuropathy Consortium 13th–15th April 2007, Schiphol, The Netherlands. Neuromuscul Disord 2008; 18:85-9. [PMID: 17869518 DOI: 10.1016/j.nmd.2007.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Revised: 07/30/2007] [Accepted: 08/10/2007] [Indexed: 11/19/2022]
Affiliation(s)
- M P Lunn
- Centre for Neuromuscular Disease, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, United Kingdom.
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15
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Abstract
BACKGROUND Serum monoclonal anti-Myelin Associated Glycoprotein antibodies may be pathogenic in some patients with IgM paraprotein and demyelinating neuropathy. Immunotherapies aimed at reducing the level of these antibodies might be expected to be of benefit in the treatment of the neuropathy. Many potential therapies have been described in small trials, uncontrolled studies and case reports. OBJECTIVES To examine the efficacy of any form of immunotherapy in reducing disability and impairment resulting from IgM anti-Myelin Associated Glycoprotein paraprotein-associated demyelinating peripheral neuropathy. SEARCH STRATEGY We searched the Cochrane Neuromuscular Disease Group register (August 2002) and MEDLINE (January 1966 - August 2002) and EMBASE (January 1980 - August 2002) for controlled trials, checked the bibliographies to identify other controlled trials and contacted authors and other experts in the field. SELECTION CRITERIA Types of studies: randomised or quasi-randomised controlled trials. TYPES OF PARTICIPANTS patients of any age with anti-Myelin Associated Glycoprotein antibody associated demyelinating peripheral neuropathy with monoclonal gammopathy of undetermined significance of any severity. Types of interventions: any type of immunotherapy. Types of outcome measures: Primary: improvement in the Neuropathy Disability Score or Modified Rankin Scale six months after randomisation Secondary: Neuropathy Disability Score and/or the Modified Rankin Score 12 months after randomisation. Ten metre walk time, subjective clinical scores and electrophysiological parameters at six and 12 months after randomisation. IgM paraprotein levels and anti-Myelin Associated Glycoprotein antibody titres six months after randomisation. Adverse effects of treatments. DATA COLLECTION AND ANALYSIS We identified six randomised controlled trials of which five were included after discussion between the authors. One author extracted the data and the other checked them. No missing data could be obtained from authors. MAIN RESULTS The five eligible trials used four of the many available immunotherapy treatments. Only two had comparable interventions and outcomes but these were only short-term studies. There were no significant benefits of the treatments used in the predefined outcomes. However intravenous immunoglobulin showed benefits in terms of improved Modified Rankin Scale at two weeks and 10 metre walk time at four weeks. Serious adverse effects of intravenous immunoglobulin are known to occur from observational studies but none were encountered in these trials. REVIEWER'S CONCLUSIONS There is inadequate reliable evidence from trials of immunotherapies in anti-Myelin Associated Glycoprotein paraproteinaemic neuropathy to recommend any particular immunotherapy treatment. Intravenous immunoglobulin is relatively safe and may produce some short-term benefit. Large well designed randomised trials are required to assess the efficacy of promising new therapies.
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Affiliation(s)
- M P Lunn
- Clinical Neurosciences, GKT School of Medicine, 2nd Floor Hodgkin Building, Guy's Hospital, London, UK, SE1 1UL.
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16
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Lunn MP, Johnson LA, Fromholt SE, Itonori S, Huang J, Vyas AA, Hildreth JE, Griffin JW, Schnaar RL, Sheikh KA. High-affinity anti-ganglioside IgG antibodies raised in complex ganglioside knockout mice: reexamination of GD1a immunolocalization. J Neurochem 2000; 75:404-12. [PMID: 10854286 DOI: 10.1046/j.1471-4159.2000.0750404.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Gangliosides, sialic acid-bearing glycosphingolipids, are highly enriched in the vertebrate nervous system. Anti-ganglioside antibodies are associated with various human neuropathies, although the pathogenicity of these antibodies remains unproven. Testing the pathogenic role of anti-ganglioside antibodies will be facilitated by developing high-affinity IgG-class complement-fixing monoclonal anti-bodies against major brain gangliosides, a goal that has been difficult to achieve. In this study, mice lacking complex gangliosides were used as immune-naive hosts to raise anti-ganglioside antibodies. Wild-type mice and knockout mice with a disrupted gene for GM2/GD2 synthase (UDP-N-acetyl-D-galactosamine : GM3/GD3 N-acetyl-D-glactosaminyltransferase) were immunized with GD1a conjugated to keyhole limpet hemocyanin. The knockout mice produced a vigorous anti-GD1a IgG response, whereas wildtype littermates failed to do so. Fusion of spleen cells from an immunized knockout mouse with myeloma cells yielded numerous IgG anti-GD1a antibody-producing colonies. Ganglioside binding studies revealed two specificity classes; one colony representing each class was cloned and characterized. High-affinity monoclonal antibody was produced by each hybridoma : an IgG1 that bound nearly exclusively to GD1a and an IgG2b that bound GD1a, GT1b, and GT1aalpha. Both antibodies readily readily detected gangliosides via ELISA, TLC immune overlay, immunohistochemistry, and immunocytochemistry. In contrast to prior reports using anti-GD1a and anti-GT1b IgM class monoclonal antibodies, the new antibodies bound avidly to granule neurons in brain tissue sections and cell cultures. Mice lacking complex gangliosides are improved hosts for raising high-affinity, high-titer anti-ganglioside IgG antibodies for probing for the distribution and physiology of gangliosides and the pathophysiology of anti-ganglioside antibodies.
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Affiliation(s)
- M P Lunn
- Department of. Neurology. Pharmacology. Neuroscience, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Lunn MP, Muir P, Brown LJ, MacMahon EM, Gregson NA, Hughes RA. Cytomegalovirus is not associated with IgM anti-myelin-associated glycoprotein/sulphate-3-glucuronyl paragloboside antibody-associated neuropathy. Ann Neurol 1999; 46:267-70. [PMID: 10443896 DOI: 10.1002/1531-8249(199908)46:2<267::aid-ana20>3.0.co;2-m] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Monoclonal antibodies reactive with the HNK-1 epitope of myelin-associated glycoprotein (MAG) and the sulphate-3-glucuronyl paragloboside (SGPG)-like glycolipids are often found in the serum of patients with IgM paraprotein-associated demyelinating neuropathy. The presence of such antibodies in patients with chronic polyneuropathy has recently been associated with evidence of active cytomegalovirus (CMV) infection by the polymerase chain reaction. We wished to test these findings and examined sera from patients with MAG-reactive or MAG-nonreactive paraproteinemic neuropathy and patients with paraproteinemia only for the presence of CMV DNA and anti-CMV antibodies. CMV DNA was not detected in sera from any patient group. Furthermore, anti-CMV antibody prevalence was normal and similar in all 3 groups. We therefore report no evidence of an association between CMV infection and anti-MAG/SGPG antibodies associated with paraproteinemic peripheral neuropathy.
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Affiliation(s)
- M P Lunn
- Department of Clinical Neurosciences, Guy's Hospital, London, United Kingdom
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Hadden RD, Lunn MP, Hughes RA. Autoimmune inflammatory neuropathy. J R Coll Physicians Lond 1999; 33:219-24. [PMID: 10402567 PMCID: PMC9665644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- R D Hadden
- Guy's, King's and St Thomas' School of Medicine, London
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Abstract
OBJECTIVES To evaluate the response of four patients with IgM paraproteinaemic neuropathy to a novel therapy-pulsed intravenous fludarabine. BACKGROUND The peripheral neuropathy associated with IgM paraproteinaemia usually runs a chronic, slowly progressive course which may eventually cause severe disability. Treatment with conventional immunosuppressive regimens has been unsatisfactory. Fludarabine is a novel purine analogue which has recently been shown to be effective in low grade lymphoid malignancies. METHODS Four patients were treated with IgM paraproteinaemic neuropathy with intravenous pulses of fludarabine. Two of the four patients had antibodies to MAG and characteristic widely spaced myelin on nerve biopsy and a third had characteristic widely spaced myelin only. The fourth had an endoneurial lymphocytic infiltrate on nerve biopsy and a diagnosis of Waldenström's macroglobulinaemia. RESULTS In all cases subjective and objective clinical improvement occurred associated with a significant fall in the IgM paraprotein concentration in three cases. Neurophysiological parameters improved in the three patients examined. The treatment was well tolerated. All patients developed mild, reversible lymphopenia and 50% mild generalised myelosuppression, but there were no febrile episodes. CONCLUSION Fludarabine should be considered as a possible treatment for patients with IgM MGUS paraproteinaemic neuropathy.
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Affiliation(s)
- H C Wilson
- Department of Clinical Neuroscience, GKT School of Medicine, Guy's Hospital, London, UK
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Lunn MP, Manji H, Choudhary PP, Hughes RA, Thomas PK. Chronic inflammatory demyelinating polyradiculoneuropathy: a prevalence study in south east England. J Neurol Neurosurg Psychiatry 1999; 66:677-80. [PMID: 10209187 PMCID: PMC1736351 DOI: 10.1136/jnnp.66.5.677] [Citation(s) in RCA: 179] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Although there are now widely accepted diagnostic criteria for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) there are few epidemiological data. A prevalence study was performed in the four Thames health regions, population 14 049 850. The prevalence date was 1 January 1995. Data were from a national consultant neurologist surveillance programme and the personal case series of two investigators. A diagnosis of CIDP was made according to definite, probable, possible, or suggestive diagnostic criteria. A wide difference in prevalence rates between the four health regions was noted, probably due to reporting bias. In the South East Thames Region, from which the data were most comprehensive the prevalence for definite and probable cases was 1.00/100 000; the highest total prevalence (if possible and suggestive cases were included) would have been 1.24/100 000. On the prevalence date 13% of patients required aid to walk and 54% were still receiving treatment.
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Affiliation(s)
- M P Lunn
- Department of Clinical Neurosciences, Hodgkin Building, Guy's Hospital, London Bridge, London, UK
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