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Lewis RA, van Doorn PA, Sommer C. Tips in navigating the diagnostic complexities of chronic inflammatory demyelinating polyradiculoneuropathy. J Neurol Sci 2022; 443:120478. [PMID: 36368137 DOI: 10.1016/j.jns.2022.120478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/29/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
The 2021 guideline of the European Academy of Neurology/Peripheral Nerve Society on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) includes important revisions to the previous 2010 guideline. This article highlights the new criteria and recommendations for the differential diagnosis of CIDP. In the revised guideline, the CIDP spectrum has been modified to include typical CIDP and four well-characterized CIDP variants, namely distal, multifocal/focal, motor and sensory CIDP, replacing the term 'atypical' CIDP. To improve the diagnosis of CIDP, the revised guideline attempts to improve the specificity of the diagnostic criteria for typical CIDP and the four CIDP variants. Specific clinical and electrodiagnostic (including both motor and sensory conduction) criteria are provided for typical CIDP and each of the CIDP variants. The levels of diagnostic certainty have been changed to CIDP and possible CIDP, with the removal of probable CIDP (due to the lack of difference in the accuracy of the electrodiagnostic criteria for probable CIDP) and definite CIDP (due to the lack of a gold standard for diagnosis). If the clinical and electrodiagnostic criteria allow only for a diagnosis of possible CIDP, cerebrospinal fluid analysis, nerve ultrasound, nerve magnetic resonance imaging, objective treatment response, and nerve biopsy can be used as supportive criteria to upgrade the diagnosis to CIDP. Although the revised guideline needs to be validated and its strengths and weaknesses assessed, using the guideline will likely improve the accuracy of diagnosis of CIDP and variants of CIDP, and aid in distinguishing CIDP from conditions with similar features.
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Affiliation(s)
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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2
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Relevance of Nerve Biopsy in the Diagnosis of Chronic Inflammatory Demyelinating Polyneuropathy—A Systematic Review. Diagnostics (Basel) 2022; 12:diagnostics12071691. [PMID: 35885595 PMCID: PMC9315483 DOI: 10.3390/diagnostics12071691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 11/24/2022] Open
Abstract
Chronic Inflammatory Demyelinating Polyneuropathy is an immune-mediated pathology of the peripheral nerves and nerve roots that leads to weakness and sensory symptoms. Given its clinical heterogeneity, often times diagnosis is challenging. Even though nerve conduction studies and clinical features are the main criteria used for diagnosis, supplementary investigations, such as nerve biopsies, cerebral spinal fluid examination and magnetic resonance studies, may be used in order to confirm the diagnosis. Given the fact that the hallmark in CIDP physiopathology is the demyelination process, nerve biopsies are used to demonstrate and assess the magnitude of the phenomenon. The question and the main interest of this review is whether histopathological findings are relevant for the diagnosis and can be useful in disease assessment.
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Nathani D, Spies J, Barnett MH, Pollard J, Wang M, Sommer C, Kiernan MC. Nerve biopsy: Current indications and decision tools. Muscle Nerve 2021; 64:125-139. [PMID: 33629393 PMCID: PMC8359441 DOI: 10.1002/mus.27201] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 02/06/2023]
Abstract
After initial investigation of patients presenting with symptoms suggestive of neuropathy, a clinical decision is made for a minority of patients to undergo further assessment with nerve biopsy. Many nerve biopsies do not demonstrate a definitive pathological diagnosis and there is considerable cost and morbidity associated with the procedure. This highlights the need for appropriate selection of patients, nerves and neuropathology techniques. Additionally, concomitant muscle and skin biopsies may improve the diagnostic yield in some cases. Several advances have been made in diagnostics in recent years, particularly in genomics. The indications for nerve biopsy have consequently changed over time. This review explores the current indications for nerve biopsies and some of the issues surrounding its use. Also included are comments on alternative diagnostic modalities that may help to supplant or reduce the use of nerve biopsy as a diagnostic test. These primarily include extraneural biopsy and neuroimaging techniques such as magnetic resonance neurography and nerve ultrasound. Finally, we propose an algorithm to assist in deciding when to perform nerve biopsies.
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Affiliation(s)
- Dev Nathani
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Judith Spies
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Michael H. Barnett
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - John Pollard
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Min‐Xia Wang
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Claudia Sommer
- Neurologische KlinikUniversitätsklinikum WürzburgWürzburgGermany
| | - Matthew C. Kiernan
- Brain and Mind CentreUniversity of SydneySydneyNew South WalesAustralia
- Institute of Clinical Neuroscience, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
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4
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Van den Bergh PYK, van Doorn PA, Hadden RDM, Avau B, Vankrunkelsven P, Allen JA, Attarian S, Blomkwist-Markens PH, Cornblath DR, Eftimov F, Goedee HS, Harbo T, Kuwabara S, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Sommer C, Topaloglu HA. European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force-Second revision. Eur J Neurol 2021; 28:3556-3583. [PMID: 34327760 DOI: 10.1111/ene.14959] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To revise the 2010 consensus guideline on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). METHODS Seventeen disease experts, a patient representative, and two Cochrane methodologists constructed 12 Population/Intervention/Comparison/Outcome (PICO) questions regarding diagnosis and treatment to guide the literature search. Data were extracted and summarized in GRADE summary of findings (for treatment PICOs) or evidence tables (for diagnostic PICOs). RESULTS Statements were prepared according to the GRADE Evidence-to-Decision frameworks. Typical CIDP and CIDP variants were distinguished. The previous term "atypical CIDP" was replaced by "CIDP variants" because these are well characterized entities (multifocal, focal, distal, motor, or sensory CIDP). The levels of diagnostic certainty were reduced from three (definite, probable, possible CIDP) to only two (CIDP and possible CIDP), because the diagnostic accuracy of criteria for probable and definite CIDP did not significantly differ. Good Practice Points were formulated for supportive criteria and investigations to be considered to diagnose CIDP. The principal treatment recommendations were: (a) intravenous immunoglobulin (IVIg) or corticosteroids are strongly recommended as initial treatment in typical CIDP and CIDP variants; (b) plasma exchange is strongly recommended if IVIg and corticosteroids are ineffective; (c) IVIg should be considered as first-line treatment in motor CIDP (Good Practice Point); (d) for maintenance treatment, IVIg, subcutaneous immunoglobulin or corticosteroids are recommended; (e) if the maintenance dose of any of these is high, consider either combination treatments or adding an immunosuppressant or immunomodulatory drug (Good Practice Point); and (f) if pain is present, consider drugs against neuropathic pain and multidisciplinary management (Good Practice Point).
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Affiliation(s)
- Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium and CEBaP, Belgian Red Cross, Mechelen, Belgium
| | | | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neuromuscular Disorders, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Århus University Hospital, Århus, Denmark
| | - Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Center, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit-Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Claudia Sommer
- Neurology Clinic, University Hospital Würzburg, Würzburg, Germany
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5
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Van den Bergh PYK, van Doorn PA, Hadden RDM, Avau B, Vankrunkelsven P, Allen JA, Attarian S, Blomkwist-Markens PH, Cornblath DR, Eftimov F, Goedee HS, Harbo T, Kuwabara S, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Sommer C, Topaloglu HA. European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force-Second revision. J Peripher Nerv Syst 2021; 26:242-268. [PMID: 34085743 DOI: 10.1111/jns.12455] [Citation(s) in RCA: 143] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022]
Abstract
To revise the 2010 consensus guideline on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Seventeen disease experts, a patient representative, and two Cochrane methodologists constructed 12 Population/Intervention/Comparison/Outcome (PICO) questions regarding diagnosis and treatment to guide the literature search. Data were extracted and summarized in GRADE summary of findings (for treatment PICOs) or evidence tables (for diagnostic PICOs). Statements were prepared according to the GRADE Evidence-to-Decision frameworks. Typical CIDP and CIDP variants were distinguished. The previous term "atypical CIDP" was replaced by "CIDP variants" because these are well characterized entities (multifocal, focal, distal, motor, or sensory CIDP). The levels of diagnostic certainty were reduced from three (definite, probable, possible CIDP) to only two (CIDP and possible CIDP), because the diagnostic accuracy of criteria for probable and definite CIDP did not significantly differ. Good Practice Points were formulated for supportive criteria and investigations to be considered to diagnose CIDP. The principal treatment recommendations were: (a) intravenous immunoglobulin (IVIg) or corticosteroids are strongly recommended as initial treatment in typical CIDP and CIDP variants; (b) plasma exchange is strongly recommended if IVIg and corticosteroids are ineffective; (c) IVIg should be considered as first-line treatment in motor CIDP (Good Practice Point); (d) for maintenance treatment, IVIg, subcutaneous immunoglobulin or corticosteroids are recommended; (e) if the maintenance dose of any of these is high, consider either combination treatments or adding an immunosuppressant or immunomodulatory drug (Good Practice Point); and (f) if pain is present, consider drugs against neuropathic pain and multidisciplinary management (Good Practice Point).
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Affiliation(s)
- Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | - Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium and CEBaP, Belgian Red Cross, Mechelen, Belgium
| | | | - Jeffrey A Allen
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Filip Eftimov
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neuromuscular Disorders, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Århus University Hospital, Århus, Denmark
| | - Satoshi Kuwabara
- Department of Neurology, Chiba University Hospital, Chiba, Japan
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Center, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit-Neurology Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Yusuf A Rajabally
- Regional Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Claudia Sommer
- Neurology Clinic, University Hospital Würzburg, Würzburg, Germany
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Moss KR, Bopp TS, Johnson AE, Höke A. New evidence for secondary axonal degeneration in demyelinating neuropathies. Neurosci Lett 2021; 744:135595. [PMID: 33359733 PMCID: PMC7852893 DOI: 10.1016/j.neulet.2020.135595] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/31/2020] [Accepted: 12/19/2020] [Indexed: 12/28/2022]
Abstract
Development of peripheral nervous system (PNS) myelin involves a coordinated series of events between growing axons and the Schwann cell (SC) progenitors that will eventually ensheath them. Myelin sheaths have evolved out of necessity to maintain rapid impulse propagation while accounting for body space constraints. However, myelinating SCs perform additional critical functions that are required to preserve axonal integrity including mitigating energy consumption by establishing the nodal architecture, regulating axon caliber by organizing axonal cytoskeleton networks, providing trophic and potentially metabolic support, possibly supplying genetic translation materials and protecting axons from toxic insults. The intermediate steps between the loss of these functions and the initiation of axon degeneration are unknown but the importance of these processes provides insightful clues. Prevalent demyelinating diseases of the PNS include the inherited neuropathies Charcot-Marie-Tooth Disease, Type 1 (CMT1) and Hereditary Neuropathy with Liability to Pressure Palsies (HNPP) and the inflammatory diseases Acute Inflammatory Demyelinating Polyneuropathy (AIDP) and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP). Secondary axon degeneration is a common feature of demyelinating neuropathies and this process is often correlated with clinical deficits and long-lasting disability in patients. There is abundant electrophysiological and histological evidence for secondary axon degeneration in patients and rodent models of PNS demyelinating diseases. Fully understanding the involvement of secondary axon degeneration in these diseases is essential for expanding our knowledge of disease pathogenesis and prognosis, which will be essential for developing novel therapeutic strategies.
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Affiliation(s)
- Kathryn R Moss
- Department of Neurology, Neuromuscular Division, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Taylor S Bopp
- Department of Neurology, Neuromuscular Division, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Anna E Johnson
- Department of Neurology, Neuromuscular Division, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Ahmet Höke
- Department of Neurology, Neuromuscular Division, Johns Hopkins School of Medicine, Baltimore, MD, United States.
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Anagnostouli M, Vakrakou AG, Zambelis T, Boufidou F, Nikolaou C, Karandreas N, Kilidireas C. Myasthenia gravis, atypical polyneuropathy and multiple autoimmune phenomena in the same patient, with HLA-immunogenetic profile expectable for Greek chronic inflammatory demyelinating polyneuropathy: a case report. Int J Neurosci 2020; 132:593-600. [PMID: 32988257 DOI: 10.1080/00207454.2020.1829616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE The comorbidity of myasthenia gravis (MG), with other autoimmune disorders like systemic lupus erythematosus (SLE), is relatively frequent but the co-occurrence with chronic inflammatory demyelinating polyneuropathy (CIDP) along with various autoimmune manifestations in the absence of thymoma is of extreme rarity. Our aim is to report a case of a woman who presented the concomitant appearance of MG, axonal sensory-motor polyneuropathy and hepatitis that may indicate an underlying pathogenetic link among the different autoimmune disorders. MATERIALS AND METHODS/RESULTS We present a case of a 54-year-old woman, with a generalized MG and a chronic sensory-motor polyneuropathy, hypothyroidism, anaemia, hepatitis, livedo reticularis and facial flush, of assumed autoimmune background, like SLE, although with persistent negative ANA antibodies, from the beginning and through the whole following years. The Human Leukocyte Antigen (HLA)-DRB1 genotyping showed a profile of alleles (DRB1*11:01/11:04) compatible with CIDP of mainly female gender in Greece and frequencies close to those of Sjogren's syndrome and scleroderma's in the Greek population. The diagnostic problems, the atypical clinical, electrophysiological and immunological features are discussed, along with the rarity of the case, with this exceptional combination of autoimmune manifestations, which could be truly associated under the clinical umbrella of a systemic disease, like SLE. However, our patient did not ever fulfil the SLE criteria. CONCLUSIONS To raise awareness among clinicians about the exceptional combination of autoimmune manifestations driven by a specific HLA background.
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Affiliation(s)
- Maria Anagnostouli
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Immunogenetics Laboratory, 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Aigli G Vakrakou
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Thomas Zambelis
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Laboratory of Electrophysiology, 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Fotini Boufidou
- Department of Biopathology and Immunology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Chrysoula Nikolaou
- Department of Biopathology and Immunology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Nikolaos Karandreas
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Laboratory of Electrophysiology, 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
| | - Constantinos Kilidireas
- 1st Department of Neurology, Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece.,Neuroimmunology Laboratory, 1st Department of Neurology of Medical School of Athens National and Kapodistrian University, NKUA, Aeginition Hospital, Athens, Greece
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8
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Cao D, Guo X, Yuan T, Hao J. Diagnosing chronic inflammatory demyelinating polyradiculoneuropathy with triple stimulation technique. J Neurol 2018; 265:1916-1921. [PMID: 29926221 DOI: 10.1007/s00415-018-8929-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/04/2018] [Accepted: 06/05/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the value of triple stimulation technique (TST) for diagnose of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). METHODS Seven clinically suspected CIDP patients who did not fulfill EFNS/PNS electrodiagnostic criteria for demyelinating neuropathy were enrolled in our study. Routine nerve conduction studies, lumbar puncture, spinal cord magnetic resonance imaging and TST were detected. The patients were being treated with oral prednisone starting at 1 mg/kg daily. The overall disability sum score was performed to evaluate the effect of corticosteroids. RESULTS Twenty-eight motor nerves were tested with TST, two conduction blocks (CBs) were detected between the root emergence and the Erb point in six patients respectively and one CB was detected in one patient. Symptoms of all seven patients improved after treatment with oral prednisone. CONCLUSION TST can detect CBs located between the root emergence and the Erb point. TST is useful for early diagnosis of CIDP.
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Affiliation(s)
- Du Cao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Friendship Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Xiuming Guo
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Friendship Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China.
| | - Ting Yuan
- Department of Neurology, 363 Hospital, Chengdu, China
| | - Jie Hao
- Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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9
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Chaturvedi S, Pant I, Jha K, Singh R, Kushwaha S. Peripheral neuropathy and the role of nerve biopsy: A revisit. INDIAN J PATHOL MICR 2018; 61:339-344. [DOI: 10.4103/ijpm.ijpm_402_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Abraham H, Kuzhively J, Rizvi SW. Chronic Inflammatory Demyelinating Polyneuropathy (CIDP): An Uncommon Manifestation of Systemic Lupus Erythematosus (SLE). AMERICAN JOURNAL OF CASE REPORTS 2017; 18:980-983. [PMID: 28894082 PMCID: PMC5604309 DOI: 10.12659/ajcr.903541] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyneuropathy (CIDP) is an uncommon manifestation of systemic lupus erythematosus (SLE). We report a case of SLE presenting as CIDP and discuss the diagnosis, management, and prognosis of CIDP. CASE REPORT A 40-year-old woman with a past medical history of SLE treated with hydroxychloroquine presented with bilateral, progressive, ascending, sensory and motor neuropathy. Physical examination showed weakness and reduced temperature of all extremities, reduced pinprick and vibration sense of the distal extremities, loss of reflexes, and walking with a wide-based unsteady gait. Laboratory investigations showed positive antinuclear antibodies (ANA), anti-(smooth muscle (SM) antibody, anti-RNP antibody, anti-SSA antibody, anti-ds-DNA antibody, and an erythrocyte sedimentation rate (ESR) of 75 mm/hr, low C4, leukopenia, and anemia. Electromyography (EMG) confirmed the diagnosis of CIDP. The patient's neuropathy and muscle weakness improved on treatment with intravenous immunoglobulin (IVIG) and high-dose steroids. CONCLUSIONS The early clinical diagnosis of CIDP, supported by serological autoantibody profiles associated with SLE, can predict a good response to steroids. Most patients with CIDP are treated successfully with steroids if the diagnosis is made early. IVIG, plasmapheresis, or immunosuppressive therapy should be considered if there is no response to steroids.
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Affiliation(s)
- Hrudya Abraham
- Division of Rheumatology, Department of Internal Medicine, MacNeal Hospital, Berwyn, IL, USA
| | - Jose Kuzhively
- Division of Endocrinology and Metabolism, Rush University Medical Center, Chicago, IL, USA
| | - Syed W Rizvi
- Division of Rheumatology, MacNeal Hospital, Berwyn, IL, USA
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11
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Goldman AS, Schmalstieg EJ, Dreyer CF, Schmalstieg FC, Goldman DA. Franklin Delano Roosevelt's (FDR's) (1882-1945) 1921 neurological disease revisited; the most likely diagnosis remains Guillain-Barré syndrome. JOURNAL OF MEDICAL BIOGRAPHY 2016; 24:452-459. [PMID: 26508622 DOI: 10.1177/0967772015605738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
In 2003, we published evidence that the most likely cause of FDR's 1921 neurological disease was Guillain-Barré syndrome. Afterwards, several historians and neurologists stated in their publications that FDR had paralytic poliomyelitis. However, significant criticism of our article or new support for that diagnosis was not revealed. One critic claimed that FDR's cerebrospinal fluid indicated poliomyelitis, but we did not find evidence that a lumbar puncture was performed. The diagnosis of FDR's neurological disease still depends upon documented clinical abnormalities. His age, prolonged symmetric ascending paralysis, transient numbness, protracted dysaesthesia (pain on slight touch), facial paralysis, bladder and bowel dysfunction, and absence of meningismus are typical of Guillain-Barré syndrome and are inconsistent with paralytic poliomyelitis. FDR's prolonged fever was atypical for both diseases. Finally, permanent paralysis, though commoner in paralytic poliomyelitis, is frequent in Guillain-Barré syndrome. Thus, the clinical findings indicate the most likely diagnosis in FDR's case remains Guillain-Barré syndrome.
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12
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Lotan I, Hellman MA, Steiner I. Diagnostic criteria of chronic inflammatory demyelinating polyneuropathy in diabetes mellitus. Acta Neurol Scand 2015; 132:278-83. [PMID: 25819084 DOI: 10.1111/ane.12394] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The possibility of co-association between diabetes mellitus (DM) and chronic inflammatory demyelinating polyneuropathy (CIDP) has long been a focus of interest as well as of clinical significance. As CIDP is a potentially treatable condition, it is diagnosis in the context of DM is of great importance. However, diagnostic criteria to identify CIDP in patients with diabetes are not available. We propose a diagnostic tool that should help clinicians to decide what is the probability that a patient with diabetes might have CIDP. METHODS We list several clinical, electrophysiological, and laboratory parameters that, when combined, have the power of discriminating an immune-mediated neuropathy in patients with DM. By summing the points assigned to each of these parameters, we define four levels of probability for a patient with diabetes to have CIDP. To analyze the validity of the diagnostic toll, we applied it in three different patient populations: (i) Patients with diabetes with peripheral neuropathy, (ii) Patients with CIDP without DM, and (iii) Patients with diabetes with CIDP. RESULTS The scores of patients with diabetes without CIDP ranged from -7 to 2, while those of patients with DM-CIDP ranged from 2 to 20. The scores of non-diabetic patients with CIDP were similar to those of patients with DM-CIDP and ranged from 6 to 16. The mean score of patients with DM-CIDP was 9.083, while the score of patients with CIDP was 11.16 and that of patients with diabetic polyneuropathy was -3.59. CONCLUSIONS These results show that this diagnostic tool is able to identify patients with diabetes with overlapping CIDP.
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Affiliation(s)
- I. Lotan
- Department of Neurology; Rabin Medical Center; Beilinson Campus; PetachTikva; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - M. A. Hellman
- Department of Neurology; Rabin Medical Center; Beilinson Campus; PetachTikva; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - I. Steiner
- Department of Neurology; Rabin Medical Center; Beilinson Campus; PetachTikva; Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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13
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Abstract
Chronic neuropathies are operationally classified as primarily demyelinating or axonal, on the basis of electrodiagnostic or pathological criteria. Demyelinating neuropathies are further classified as hereditary or acquired-this distinction is important, because the acquired neuropathies are immune-mediated and, thus, amenable to treatment. The acquired chronic demyelinating neuropathies include chronic inflammatory demyelinating polyneuropathy (CIDP), neuropathy associated with monoclonal IgM antibodies to myelin-associated glycoprotein (MAG; anti-MAG neuropathy), multifocal motor neuropathy (MMN), and POEMS syndrome. They have characteristic--though overlapping--clinical presentations, are mediated by distinct immune mechanisms, and respond to different therapies. CIDP is the default diagnosis if the neuropathy is demyelinating and no other cause is found. Anti-MAG neuropathy is diagnosed on the basis of the presence of anti-MAG antibodies, MMN is characterized by multifocal weakness and motor conduction blocks, and POEMS syndrome is associated with IgG or IgA λ-type monoclonal gammopathy and osteosclerotic myeloma. The correct diagnosis, however, can be difficult to make in patients with atypical or overlapping presentations, or nondefinitive laboratory studies. First-line treatments include intravenous immunoglobulin (IVIg), corticosteroids or plasmapheresis for CIDP; IVIg for MMN; rituximab for anti-MAG neuropathy; and irradiation or chemotherapy for POEMS syndrome. A correct diagnosis is required for choosing the appropriate treatment, with the aim of preventing progressive neuropathy.
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Affiliation(s)
- Norman Latov
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, 1305 York Avenue, Suite 217, New York, NY 10021, USA
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14
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Padua L, Granata G, Sabatelli M, Inghilleri M, Lucchetta M, Luigetti M, Coraci D, Martinoli C, Briani C. Heterogeneity of root and nerve ultrasound pattern in CIDP patients. Clin Neurophysiol 2013; 125:160-5. [PMID: 24099922 DOI: 10.1016/j.clinph.2013.07.023] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 06/25/2013] [Accepted: 07/20/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The few published ultrasound (US) studies on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) report diffusely increased cross-sectional area (CSA) of nerves. The data are, however, heterogeneous and correlations with clinical history or disease severity are lacking. METHODS Thirty-four patients with CIDP underwent US nerve evaluation by two neurologists blinded to clinical data. US nerve pattern for each patient was defined by a third neurologist blinded to clinical data. Three US classes were identified based on CSA and echogenicity: large nerves with hypoechoic nerves/fascicles (class 1); large nerves with heterogeneous hypo- and hyperechoic fascicles (class 2); normal size nerve but abnormal hyperechoic array (class 3). RESULTS In all patients, US nerve changes were observed: in most of the cases, enlarged nerves or nerve segments were observed. The three 'classes' of US nerve changes significantly correlated (R: 0.68, p<0.001) with disease duration, but not with age or Inflammatory Neuropathy Cause and Treatment (INCAT) disability score. CONCLUSIONS US may be of adjunctive diagnostic value in CIDP assessment. Nerve morphological changes may mirror the underlying pathophysiological mechanisms and seem to correlate with disease duration. SIGNIFICANCE These results offer the possibility of exploring the use of US to assess CIDP disease activity and treatment.
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Affiliation(s)
- L Padua
- Institute of Neurology, Catholic University, Rome, Italy; Don Carlo Gnocchi Onlus Foundation, Rome, Italy.
| | - G Granata
- Institute of Neurology, Catholic University, Rome, Italy
| | - M Sabatelli
- Institute of Neurology, Catholic University, Rome, Italy
| | - M Inghilleri
- Institute of Neurology, "Sapienza" University of Rome, Rome, Italy
| | - M Lucchetta
- Department of Neurosciences, University of Padua, Padua, Italy
| | - M Luigetti
- Institute of Neurology, Catholic University, Rome, Italy
| | - D Coraci
- Don Carlo Gnocchi Onlus Foundation, Rome, Italy
| | - C Martinoli
- Radiology Institute, "R" - DICMI, University of Genoa, Genoa, Italy
| | - C Briani
- Department of Neurosciences, University of Padua, Padua, Italy
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15
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Van den Bergh PY, Rajabally YA. Chronic inflammatory demyelinating polyradiculoneuropathy. Presse Med 2013; 42:e203-15. [DOI: 10.1016/j.lpm.2013.01.056] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 01/25/2013] [Accepted: 01/25/2013] [Indexed: 12/12/2022] Open
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16
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Abstract
Electromyography (EMG) is an important diagnostic tool for the assessment of individuals with various neuromuscular diseases. It should be an extension of a thorough history and physical examination. Some prototypical characteristics and findings of EMG and nerve conduction studies are discussed; however, a more thorough discussion can be found in the textbooks and resources sited in the article. With an increase in molecular genetic diagnostics, EMG continues to play an important role in the diagnosis and management of patients with neuromuscular diseases and also provides a cost-effective diagnostic workup before ordering a battery of costly genetic tests.
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Affiliation(s)
- Bethany M Lipa
- Department of Physical Medicine and Rehabilitation, University of California Davis School of Medicine, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA.
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17
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Said G, Krarup C. Chronic inflammatory demyelinative polyneuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2013; 115:403-13. [PMID: 23931792 DOI: 10.1016/b978-0-444-52902-2.00022-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic inflammatory demyelinative polyneuropathy (CIDP) is an acquired polyneuropathy presumably of immunological origin. It is characterized by a progressive or a relapsing course with predominant motor deficit. The diagnosis rests on the association of non-length-dependent predominantly motor deficit following a progressive or a relapsing course associated with increased CSF protein content. The demonstration of asymmetrical demyelinating features on nerve conduction studies is needed for diagnosis. The outcome depends on the amplitude of axon loss associated with demyelination. CIDP must be differentiated from acquired demyelinative neuropathies associated with monoclonal gammopathies. CIDP responds well to treatment with corticosteroids, intravenous immunoglobulins, and plasma exchanges, at least initially.
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Affiliation(s)
- Gérard Said
- Department of Neurology, Hôpital de la Salpêtrière, Paris, France.
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18
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Jani-Acsadi A, Lewis RA. Evaluation of a patient with suspected chronic demyelinating polyneuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2013; 115:253-64. [PMID: 23931785 DOI: 10.1016/b978-0-444-52902-2.00015-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Affiliation(s)
- Agnes Jani-Acsadi
- Department of Neurology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
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19
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Peltier AC, Donofrio PD. Chronic inflammatory demyelinating polyradiculoneuropathy: from bench to bedside. Semin Neurol 2012; 32:187-95. [PMID: 23117943 DOI: 10.1055/s-0032-1329194] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is the most common treatable chronic autoimmune neuropathy. Multiple diagnostic criteria have been established, with the primary goal of identifying neurophysiologic hallmarks of acquired demyelination. Treatment modalities have expanded to include numerous immunomodulatory therapies, although the best evidence continues to be for corticosteroids, plasma exchange, and intravenous immunoglobulin (IVIg). This review describes the pathology, epidemiology, pathogenesis, diagnosis, and treatment of CIDP.
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Affiliation(s)
- Amanda C Peltier
- Department of Neurology, Vanderbilt Medical Center, Medical Center North, Nashville, Tennessee 37232-2551, USA.
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20
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Abstract
Polyradiculopathies are uncommon peripheral nervous system syndromes that result from a variety of conditions. The clinical manifestations are variable but often include symmetric or asymmetric distal and proximal weakness with a variable degree of sensory loss and reduction or loss of reflexes. The most common cause of an acute polyradiculopathy is acute inflammatory demyelinating polyradiculopathy (also known as Guillain-Barré syndrome); however, other inflammatory, infectious, or neoplastic causes can present with similar features. Chronic polyradiculopathies include chronic inflammatory demyelinating polyradiculopathy as well as paraprotein-related syndromes and other inflammatory and infectious causes. Evaluation using a combination of serologic studies, electrodiagnostic testing, and CSF evaluation can help to identify the underlying etiology and implement the appropriate treatment. This article reviews the approach to patients with suspected polyradiculopathy and the features of the more common causes of acute and chronic polyradiculopathies.
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21
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Fressinaud C, Dubas F. Axon cytoskeleton ultrastructure in chronic inflammatory demyelinating polyneuropathy. Muscle Nerve 2011; 44:332-9. [DOI: 10.1002/mus.22069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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22
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Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is the most common chronic autoimmune neuropathy. Despite clinical challenges in diagnosis-owing in part to the existence of disease variants, and different views on how many electrophysiological abnormalities are needed to document demyelination-consensus criteria seem to have been reached for research or clinical practice. Current standard of care involves corticosteroids, intravenous immunoglobulin (IVIg) and/or plasmapheresis, which provide short-term benefits. Maintenance therapy with IVIg can induce sustained remission, increase quality of life and prevent further axonal loss, but caution is needed to avoid overtreatment. Commonly used immunosuppressive drugs offer minimal benefit, necessitating the development of new therapies for treatment-refractory patients. Advances in our understanding of the underlying immunopathology in CIDP have identified new targets for future therapeutic efforts, including T cells, B cells, and transmigration and transduction molecules. New biomarkers and scoring systems represent emerging tools with the potential to predict therapeutic responses and identify patients with active disease for enrollment into clinical trials. This Review highlights the recent advances in diagnosing CIDP, provides an update on the immunopathology including new target antigens, and discusses current treatments, ongoing challenges and future therapeutic directions.
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Affiliation(s)
- Marinos C Dalakas
- Neuroimmunology Unit, Department of Pathophysiology, National University of Athens Medical School, Building 16, Room 39, 75 Mikras Asias Street, Athens 11527, Greece.
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23
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24
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Bromberg MB. Review of the evolution of electrodiagnostic criteria for chronic inflammatory demyelinating polyradicoloneuropathy. Muscle Nerve 2011; 43:780-94. [DOI: 10.1002/mus.22038] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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25
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Sommer CL, Brandner S, Dyck PJ, Harati Y, LaCroix C, Lammens M, Magy L, Mellgren SI, Morbin M, Navarro C, Powell HC, Schenone AE, Tan E, Urtizberea A, Weis J. Peripheral Nerve Society Guideline on processing and evaluation of nerve biopsies. J Peripher Nerv Syst 2010; 15:164-75. [DOI: 10.1111/j.1529-8027.2010.00276.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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26
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Sartucci F, Bocci T, Borghetti D, Orlandi G, Manfredonia F, Murri L, Giannini F, Rossi A. Further insight on A-wave in acute and chronic demyelinating neuropathies. Neurol Sci 2010; 31:609-16. [DOI: 10.1007/s10072-010-0354-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 06/03/2010] [Indexed: 11/27/2022]
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27
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Isose S, Kuwabara S, Kokubun N, Sato Y, Mori M, Shibuya K, Sekiguchi Y, Nasu S, Fujimaki Y, Noto Y, Sawai S, Kanai K, Hirata K, Misawa S. Utility of the distal compound muscle action potential duration for diagnosis of demyelinating neuropathies. J Peripher Nerv Syst 2009; 14:151-8. [DOI: 10.1111/j.1529-8027.2009.00226.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Laughlin RS, Dyck PJ, Melton LJ, Leibson C, Ransom J, Dyck PJB. Incidence and prevalence of CIDP and the association of diabetes mellitus. Neurology 2009; 73:39-45. [PMID: 19564582 PMCID: PMC2707109 DOI: 10.1212/wnl.0b013e3181aaea47] [Citation(s) in RCA: 198] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The reported prevalence of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) varies greatly, from 1.9 to 7.7 per 100,000. CIDP is reported to occur more commonly in patients with diabetes mellitus (DM) but has not been rigorously tested. OBJECTIVES To determine the incidence (1982-2001) and prevalence (on January 1, 2000) of CIDP in Olmsted County, Minnesota, and whether DM is more frequent in CIDP. METHODS CIDP was diagnosed by clinical criteria followed by review of electrophysiology. Cases were coded as definite, probable, or possible. DM was ascertained by clinical diagnosis or current American Diabetes Association glycemia criteria. RESULTS One thousand five hundred eighty-one medical records were reviewed, and 23 patients (10 women and 13 men) were identified as having CIDP (19 definite and 4 probable). The median age was 58 years (range 4-83 years), with a median disease duration at diagnosis of 10 months (range 2-64 months). The incidence of CIDP was 1.6/100,000/year. The prevalence was 8.9/100,000 persons on January 1, 2000. Only 1 of the 23 CIDP patients (4%) also had DM, whereas 14 of 115 age- and sex-matched controls (12%) had DM. CONCLUSIONS 1) The incidence (1.6/100,000/year) and prevalence (8.9/100,000) of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are similar to or higher than previous estimates. 2) The incidence of CIDP is similar to that of acute inflammatory demyelinating polyradiculoneuropathy within the same population. 3) Diabetes mellitus (DM) is unlikely to be a major risk covariate for CIDP, but we cannot exclude a small effect. 4) The perceived association of DM with CIDP may be due to misclassification of other forms of diabetic neuropathies and excessive emphasis on electrophysiologic criteria.
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Affiliation(s)
- R S Laughlin
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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29
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Demyelinating findings in typical and atypical chronic inflammatory demyelinating polyneuropathy: sensitivity and specificity. J Clin Neuromuscul Dis 2009; 10:163-9. [PMID: 19494726 DOI: 10.1097/cnd.0b013e31819a71e1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate how the number of demyelinating findings (DF) on nerve conductions affects sensitivity and specificity of electrodiagnostic criteria for chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS Electrodiagnostic findings of 26 consecutive patients with CIDP were compared with amyotrophic lateral sclerosis (ALS) and diabetic polyneuropathy controls. Patients with CIDP were divided into typical and atypical CIDP, as defined elsewhere. RESULTS Depending on the minimal required number (MRN) of DF on nerve conductions, sensitivities decreased from an arbitrary 100% to 58% and 54%, for an MRN of 1, 2, and 3, respectively, as specificities increased, from 48% to 81% and 95%, respectively. The number of DF per patient was higher in typical CIDP than in atypical CIDP. CONCLUSIONS The considerable gap between specificity and sensitivity is the reason for controversy regarding the MRN for the diagnosis of CIDP. Requiring 2 or more DFs to identify CIDP increases specificity from 48% to 81% but lowers sensitivity from 100% to 58%. For patients with other potential causes of neuropathy, the requirement of 2 or more DFs could further increase specificity.
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30
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Recommendations on diagnostic strategies for chronic inflammatory demyelinating polyradiculoneuropathy. J Neurol Neurosurg Psychiatry 2008; 84:378-81. [PMID: 18202204 DOI: 10.1136/jnnp.2006.109785] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune mediated treatable peripheral neuropathy, the diagnosis of which is straightforward in more than half of cases. Numerous sets of electrophysiological criteria have been published. However, in some cases, electrophysiological data are not sufficient and patients that may benefit from treatment escape accurate diagnosis. OBJECTIVE To describe a step by step diagnostic procedure for neurologists facing a peripheral neuropathy of undetermined cause, to help make an accurate diagnosis of CIDP. METHODS A group of French experts was established, neurologists and neurophysiologists being recruited on the basis of personal experience with patients suffering from CIDP and also on publications in the field. A full literature review was conducted on the topic of diagnostic criteria and procedures for the diagnosis of CIDP, and meetings were scheduled to reach a consensus on the best diagnostic workup in different clinical situations. RESULTS Six meetings were conducted and a consensus was reached, based on the available literature and experience in the management of such patients. Discussions resulted in defining five clinical situations in which a diagnosis of CIDP may be considered, and procedures were detailed in each case, including the location of nerve biopsy and use of non-conventional electrophysiological testing and imaging procedures. CONCLUSION The guidelines in the diagnostic procedure reported here result from a consensus of French experts in the field of peripheral neuropathy and allow a diagnosis of CIDP to be made in the most frequently encountered situations. These recommendations may be of value for physicians as they rely on the rational use of available techniques in typical clinical situations.
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31
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147th ENMC International Workshop: Guideline on processing and evaluation of sural nerve biopsies, 15–17 December 2006, Naarden, The Netherlands. Neuromuscul Disord 2008; 18:90-6. [DOI: 10.1016/j.nmd.2007.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Indexed: 11/23/2022]
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Kalita J, Misra UK, Yadav RK. A comparative study of chronic inflammatory demyelinating polyradiculoneuropathy with and without diabetes mellitus. Eur J Neurol 2007; 14:638-43. [PMID: 17539941 DOI: 10.1111/j.1468-1331.2007.01798.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Diabetes mellitus (DM) is occasionally associated with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) raising the question of coexistence or etiological link. The study compares, neurophysiological and outcome of CIDP patients with and without DM. Consecutive CIDP patients were subjected to detailed clinical evaluation, haematology, serum chemistry, vasculitis profile, paraproteins, myeloma screening and cerebrospinal fluid (CSF) examination. Electrodiagnostic (EDx) tests included motor and sensory conduction and F-wave studies. The patients were treated with oral prednisolone 1 mg/kg/day with or without azathioprine 1-2 mg/kg and followed up for 6 months. The clinical and EDx finding in CIDP with and without DM were compared. Thirty-five CIDP patients were included and nine had DM. CIDP with diabetes (CIDP-D) had higher frequency of autonomic dysfunction. In CIDP-D, motor (38.9% vs. 16.7%) and sensory (40.7% vs. 14.1%) nerve conductions were more frequently unrecordable or had reduced compound muscle action potential (CMAP) amplitude. F-waves were also more frequently unrecordable in CIDP-D (28.8% vs. 12.8%) compared with idiopathic CIDP (I-CIDP). The degree of conduction block was more in I-CIDP. At 6-month follow up, I-CIDP patients improved better than CIDP-D. CIDP-D patients present with higher frequency of autonomic dysfunction, electrophysiological evidences of associated axonal loss and had a poorer outcome at 6 months compared with I-CIDP.
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Affiliation(s)
- J Kalita
- Department of Neurology, Sanjay Gandhi PGIMS, Lucknow, India
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33
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Maisonobe T. [Histopathological features of chronic inflammatory demyelinating polyradiculoneuropathy]. Rev Neurol (Paris) 2006; 162:527-32. [PMID: 16585916 DOI: 10.1016/s0035-3787(06)75046-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) was proposed by Dyck et al. in 1975. Diagnosis was based mainly on nerve biopsy features with segmental demyelination, onion bulb formation and inflammatory infiltrates. In many pathological studies, frequencies of these features of CIDP were not observed in the same percentages. Limitations on the nerve biopsy were explained by the study of small, distal, only sensory nerve specimens in the lower limb. In recent years, the usefulness of nerve biopsy has been reconsidered. If electron microscopy and teased-fiber studies are used, the examination can recognize CIDP erroneously classified as chronic idiopathic axonal polyneuropathy. Therapeutic options should be guided by suggestive abnormalities of demyelination and or inflammation on nerve biopsy even in the presence of a electrophysiologic axonal pattern.
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Affiliation(s)
- T Maisonobe
- Fédération de Neurophysiologie Clinique et Laboratoire de Neuropathologie R. Escourolle, Hôpital de la Pitié-Salpêtrière, Paris.
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34
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Said G. Chronic inflammatory demyelinating polyneuropathy. Neuromuscul Disord 2006; 16:293-303. [PMID: 16631367 DOI: 10.1016/j.nmd.2006.02.008] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2005] [Revised: 01/02/2006] [Accepted: 02/13/2006] [Indexed: 11/27/2022]
Abstract
Chronic inflammatory demyelinative polyneuropathy (CIDP) is an acquired neuropathy, presumably of immunological origin. Its clinical presentation and course are extremely variable. CIDP is one of the few peripheral neuropathies amenable to treatment. Typical cases associate progressive or relapsing-remitting motor and sensory deficit with increased CSF protein content and electrophysiological features of demyelination. In other instances the neuropathy is predominantly or exclusively motor or sensory, CSF normal and electrophysiological studies fail to show evidence of demyelination. In such cases conventional diagnostic criteria are not filled yet the patient may respond to immunomodulatory treatments. In this paper we review the diagnostic pitfalls and clinical variants of CIDP to illustrate the problems that may arise. The different therapeutic options are reviewed. Axon loss associated with demyelination is the most important factor of disability and resistance to treatment.
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Affiliation(s)
- Gérard Said
- Service de Neurologie, Hôpital de Bicêtre, Assistance Publique Hopitaux de Paris, Université Paris-Sud, 94275 Le Kremlin-Bicêtre, France.
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35
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Stamboulis E, Katsaros N, Koutsis G, Iakovidou H, Giannakopoulou A, Simintzi I. Clinical and subclinical autonomic dysfunction in chronic inflammatory demyelinating polyradiculoneuropathy. Muscle Nerve 2006; 33:78-84. [PMID: 16184605 DOI: 10.1002/mus.20438] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Autonomic neuropathy, although common in Guillain-Barré syndrome, is considered rare in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and has not been systematically investigated in that disorder. The present study was aimed at determining the prevalence of autonomic dysfunction and investigating the integrity of autonomic nervous system (ANS) reflexes in CIDP. We studied 17 patients with idiopathic CIDP and 20 healthy controls. Six quantitative autonomic function tests (AFTs) were used: Valsalva ratio, 30/15 ratio, and inspiration-expiration difference for parasympathetic function; and tilt test, handgrip test, and sympathetic skin response for sympathetic function. Eleven patients had symptoms of autonomic dysfunction. AFTs were abnormal in 13 patients. Parasympathetic and sympathetic systems were affected with equal frequency. The tilt test was abnormal most frequently, followed by the 30/15 ratio. Three patients developed postural hypotension with loss of consciousness during the tilt test. Abnormality of AFTs did not correlate with the presence of dysautonomic symptoms; duration, severity, and clinical course of the disease; or with age or gender of patients. Our study suggests a higher frequency of clinical and subclinical involvement of the ANS in CIDP than previously estimated. Dysautonomic symptoms are frequent but are mild. However, upon prolonged passive standing, autonomic failure can lead to loss of consciousness. The subclinical involvement of the ANS affects mainly the sympathetic vasomotor and parasympathetic cardiovascular fibers.
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Affiliation(s)
- Eleftherios Stamboulis
- Department of Neurology, University of Athens, Aeginition Hospital, 74 Vas Sophias Avenue, Athens GR-115 28, Greece.
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36
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Vina ER, Fang AJ, Wallace DJ, Weisman MH. Chronic inflammatory demyelinating polyneuropathy in patients with systemic lupus erythematosus: prognosis and outcome. Semin Arthritis Rheum 2006; 35:175-84. [PMID: 16325658 DOI: 10.1016/j.semarthrit.2005.08.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To identify clinical characteristics, laboratory features, approaches to management, and predictors of outcome of chronic inflammatory demyelinating polyneuropathy (CIDP) in patients with systemic lupus erythematosus (SLE). METHODS An analysis of 6 adults with the concurrent diagnosis of CIDP and SLE seen at a SLE Clinic from 1994 to 2004 with a review of 13 patients with SLE and CIDP reported in the medical literature from 1950 through 2004. RESULTS Among our 6 patients with SLE and CIDP, 3 (50%) achieved a substantial clinical response to intravenous immunoglobulin (IVIg) and the remainder had a minimal response. The improved patients were more likely to have received treatment earlier (within 1 year of CIDP onset) and to respond faster (<1 to 3 months) than minimally improved patients. They tended to have CIDP features of weakness of all extremities, hyporeflexia of the upper extremities, and slowed nerve conduction velocity of the motor median nerve. Compared with minimal responders, responders had more serious internal organ manifestations and multiple autoantibodies associated with SLE. Review of the literature identified 13 previously reported CIDP patients with SLE. Many had neurological involvement of all extremities, nerve biopsies showing demyelination, and serious SLE internal organ manifestations. Most were treated with steroids, but the 1 treated with IVIg had similar characteristics to our subset of patients who improved with IVIg. CONCLUSIONS CIDP is an uncommon, but not rare, manifestation of SLE. Certain characteristics including early CIDP diagnosis, involvement of all 4 extremities, hyporeflexia of the upper extremities, and slowed motor nerve conduction velocity of the median nerve in addition to SLE involvement of critical internal organs and the presence of multiple antibodies associated with SLE all appear to predict a good response to IVIg.
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Affiliation(s)
- Ernest R Vina
- Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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37
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Antoine JC, Azulay JP, Bouche P, Créange A, Fournier E, Gallouedec G, Lagueny A, Lefaucheur JP, Léger JM, Magy L, Maisonobe T, Nicolas G, Pouget J, Soichot P, Stojkovic T, Vallat JM, Verschueren A, Vial C, Viala K. Polyradiculonévrites inflammatoires démyélinisantes chroniques : stratégie diagnostique. Rev Neurol (Paris) 2005; 161:988-96. [PMID: 16365632 DOI: 10.1016/s0035-3787(05)85166-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) comprises a group of dysimmune neuropathies easily diagnosed in more than half of the patients. Diagnosis is based on clinical, electrophysiological and biological clues. In some patients, diagnosis is unclear because of the debated value of the available clues. In such circumstances, dysimmune neuropathies may not be diagnosed, leading to insufficient treatment. This is an important category of patients because immunomodulatory drugs have proven efficacy. The CIDP spectrum includes a relatively wide range of diseases. Besides the easily recognized classic forms, there are many clinical variants, sometimes with a paucisymptomatic presentation leading to uncertain diagnosis. The French CIDP study group has established guidelines for diagnostic strategy in CIDP patients. The first part of this paper is devoted to the clinical aspects of the disease, classical forms and variants. In the second part, the results of electrophysiological studies are reported. In a third chapter, complementary examinations useful for diagnosis are discussed. The fourth chapter deals with the diagnostic strategy, discussed in relation to the different situations which may be encountered in clinical practice. details the technical modalities of appropriate electrophysiological studies and presents normal results together with those indicating demyelinating neuropathy. Nerve biopsy technique and results are given in appendix II.
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Affiliation(s)
- J C Antoine
- Service et Laboratoire de Neurologie, CHU Dupuytren, Limoges
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Affiliation(s)
- G Fuller
- Department of Neurology, Gloucester Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK.
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Affiliation(s)
- Hubertus Köller
- Department of Neurology, Heinrich-Heine University, Düsseldorf, Germany
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Carvalho AAS, Vital A, Ferrer X, Latour P, Lagueny A, Brechenmacher C, Vital C. Charcot-Marie-Tooth disease type 1A: clinicopathological correlations in 24 patients. J Peripher Nerv Syst 2005; 10:85-92. [PMID: 15703022 DOI: 10.1111/j.1085-9489.2005.10112.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We examined nerve biopsies from 24 patients with Charcot-Marie-Tooth disease type 1A (CMT1A) and proven 17p11.2-12 duplication. There were seven males and 17 females with a mean age of 27.85 +/- 18.95 years at the time of nerve biopsy. A family history consistent with dominant inheritance was present in 17 patients. Clinical features were classical in 16 patients and were atypical in the other eight: one had calf hypertrophy; two had Roussy-Levy syndrome; one had had a subacute inflammatory demyelinating polyneuropathy 11 years earlier and presented a relapse on the form of a chronic inflammatory demyelinating polyneuropathy; one had carpal tunnel syndrome; one had a recent painful neuropathy in both legs; and two had chronic inflammatory demyelinating polyneuropathy. Onion bulb formations (OMFs) were present in every case and most of them were characteristic, whereas burnt-out or cluster-associated OMFs were less common. Depletion of myelinated fibers was severe in 20 cases (169-2927/mm2) and varied from 5187 to 3725/mm2 in three children (4-9 years old). In addition, features of macrophage-associated demyelination were observed in the last four atypical cases. Known for more than 20 years, inflammatory demyelination superimposed in the course of CMT1A has been reported in a few cases in the past few years, mainly concerning asymptomatic or atypical patients. Such an association deserves to be better known because corticotherapy improves weakness in most of these patients.
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Affiliation(s)
- Alzira A S Carvalho
- Neuropathology Department, Victor Segalen University, Pessac, Bordeaux, France
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Fressinaud C, Jean I, Dubas F. Modifications des neurofilaments et des microtubules axonaux en fonction du mécanisme lésionnel : étude pathologique et expérimentale. Rev Neurol (Paris) 2005; 161:55-60. [PMID: 15678001 DOI: 10.1016/s0035-3787(05)84973-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The consequences of axonal or demyelinating injuries on the axonal cytoskeleton have rarely been described. METHODS We have compared the density of fibers labeled by anti-neurofilaments (NF) and -beta tubulin (TUB) to the density of total fibers in nine patients with axonal neuropathies of undetermined etiology (AUE), six with necrotizing angeitis with neuropathy (NAN), seven with chronic inflammatory demyelinating neuropathy (CIDP) and in five controls, as well as in six patients with chronic multiple sclerosis (MS). We also studied demyelinated rat corpus callosum after lysophosphatidyl (LPC) microinjection. RESULTS In AUE and NAN NF positive fibers decreased together with total fiber density, whereas TUB increased. In demyelinating lesions TUB was not altered (CIDP) or strongly decreased (MS, LPC); NF were strongly reduced in MS (where axon loss was prominent) and in LPC lesions (despite the lack of fiber degeneration) and for fiber densities<3900/mm2 in CIDP. CONCLUSION The initial mechanism of a disease, either axonal degeneration or demyelination, could result into a specific pattern of axonal cytoskeleton alterations.
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Affiliation(s)
- C Fressinaud
- Département de Neurologie, UPRES EA 3143, CHU, Angers.
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Rocha CT, Escolar DM. Update on diagnosis and treatment of hereditary and acquired polyneuropathies in childhood. SUPPLEMENTS TO CLINICAL NEUROPHYSIOLOGY 2004; 57:255-71. [PMID: 16106624 DOI: 10.1016/s1567-424x(09)70362-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Carolina Tesi Rocha
- Department of Neurology, Research Center for Genetic Medicine, MDA Clinic, Children's National Medical Center, George Washington University, Washington, DC 20010, USA
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Gorson KC, Ropper AH. Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP): A Review of Clinical Syndromes and Treatment Approaches in Clinical Practice. J Clin Neuromuscul Dis 2003; 4:174-189. [PMID: 19078712 DOI: 10.1097/00131402-200306000-00004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is a chronic, acquired immune and inflammatory disorder of the peripheral nervous system. The classic form of the disorder is manifested by progressive or relapsing proximal or generalized limb weakness and areflexia, and usually easily recognized; it is the large number of regional and functional variants and variety of associated illnesses that pose a challenge to the clinician in practice. Similarly, laboratory and electromyography criteria have been developed to confirm the diagnosis; however, these various schemes are contrived because only 50% to 60% of patients with typical clinical features of CIDP fulfill these strict electrodiagnostic research criteria. Several studies have established the efficacy of immune therapies such as corticosteroids, plasma exchange, and intravenous immune globulin as the mainstay of treatment of CIDP, but these treatments might provide only short-term benefit. This review offers an approach to the evaluation and management of patients with CIDP and highlights the difficult clinical problems in those who do not respond or frequently relapse after treatment with standard therapies such as patients with CIDP and concomitant axonal loss, and the assessment of those with CIDP and concurrent diseases such as diabetes mellitus.
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Affiliation(s)
- Kenneth C Gorson
- From the Neurology Service, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
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Micco A, Nobile-Orazio E, Baron P, Conti G, Napoli L, Serafini M, Scarlato G, Scarpini E. Severe chronic sensory-motor polyneuropathy: coexistence of 3 unrelated etiologies in a type 1 diabetic patient. A case report and review of the literature. J Peripher Nerv Syst 2003; 8:23-8. [PMID: 12678551 DOI: 10.1046/j.1529-8027.2003.03005.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We present the case of a 58-year-old man, who has suffered from type 1 diabetes mellitus since he was young. He had monoclonal IgM kappa gammopathy of undetermined significance and high anti-MAG antibody titer. He developed a polyneuropathic picture with the clinical and laboratory features of chronic inflammatory demyelinating polyneuropathy within the span of approximately 2 years. He benefited from IV administration of high doses of immunoglobulins. Investigation of all parameters, but particularly of the clinical phenotype, can lead to a better definition of the polyneuropathic picture, especially for therapeutic and prognostic purposes.
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Affiliation(s)
- Andrea Micco
- Department of Neurological Sciences, University of Milan, IRCCS Ospedale Maggiore Policlinico, Milan, Italy.
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Sander HW, Hedley-Whyte ET. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 6-2003. A nine-year-old girl with progressive weakness and areflexia. N Engl J Med 2003; 348:735-43. [PMID: 12594319 DOI: 10.1056/nejmcpc020031] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Howard W Sander
- Peripheral Neuropathy Center and the Department of Neurology, Weill Cornell Medical College, New York, USA
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