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Naum R, Gwathmey KG. Autoimmune polyneuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:587-608. [PMID: 37562888 DOI: 10.1016/b978-0-323-98818-6.00004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
The autoimmune peripheral neuropathies with prominent motor manifestations are a diverse collection of unusual peripheral neuropathies that are appreciated in vast clinical settings. This chapter highlights the most common immune-mediated, motor predominant neuropathies excluding acute, and chronic inflammatory demyelinating polyradiculoneuropathy (AIDP and CIDP, respectively). Other acquired demyelinating neuropathies such as distal CIDP and multifocal motor neuropathy will be covered. Additionally, the radiculoplexus neuropathies, resulting from microvasculitis-induced injury to nerve roots, plexuses, and nerves, including diabetic and nondiabetic lumbosacral radiculoplexus neuropathy and neuralgic amyotrophy (i.e., Parsonage-Turner syndrome), will be included. Finally, the motor predominant peripheral neuropathies encountered in association with rheumatological disease, particularly Sjögren's syndrome and rheumatoid arthritis, are covered. Early recognition of these distinct motor predominant autoimmune neuropathies and initiation of immunomodulatory and immunosuppressant treatment likely result in improved outcomes.
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Affiliation(s)
- Ryan Naum
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
| | - Kelly Graham Gwathmey
- Neuromuscular Division, Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States.
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Abstract
Autoimmune neuropathy may present acutely or with a more progressive and/or relapsing and remitting course. Acute inflammatory neuropathy or Guillain-Barré syndrome (GBS) has variable presentations but by far the most common is acute inflammatory demyelinating polyradiculoneuropathy which is characterized by rapidly progressive proximal and distal symmetric weakness, sensory loss, and depressed reflexes. The most common chronic autoimmune neuropathy is chronic inflammatory demyelinating polyradiculoneuropathy, which in its most typical form is clinically similar to acute inflammatory demyelinating polyradiculoneuropathy (proximal and distal symmetric weakness, sensory loss, and depressed reflexes) but differs in that onset is much more gradual, i.e., over at least 8 weeks. While the majority of GBS cases result from a postinfectious activation of the immune system, presumably in a genetically susceptible host, less is understood regarding the etiopathogenesis of chronic inflammatory demyelinating polyradiculoneuropathy. Both acute and chronic forms of these inflammatory neuropathies are driven by some combination of innate and adaptive immune pathways, with differing contributions depending on the neuropathy subtype. Both disorders are largely clinical diagnoses, but diagnostic tools are available to confirm the diagnosis, prognosticate, detect variant forms, and rule out mimics. Given the autoimmune underpinnings of both disorders, immunosuppressive and immunomodulating treatments are typically given in both diseases; however, they differ in their response to treatment.
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Affiliation(s)
- Caroline Miranda
- Department of Neurology, Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, United States.
| | - Thomas H Brannagan
- Department of Neurology, Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, United States
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Stikvoort García DJL, Kovalchuk MO, Goedee HS, van Schelven LJ, van den Berg LH, Franssen H, Sleutjes BTHM. Motor unit integrity in multifocal motor neuropathy: A systematic evaluation with CMAP scans. Muscle Nerve 2021; 65:317-325. [PMID: 34854491 PMCID: PMC9300115 DOI: 10.1002/mus.27469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 11/18/2021] [Accepted: 11/23/2021] [Indexed: 11/09/2022]
Abstract
Introduction/Aims Progressive axonal loss in multifocal motor neuropathy (MMN) is often assessed with nerve conduction studies (NCS), by recording maximum compound muscle action potentials (CMAPs). However, reinnervation maintains the CMAP amplitude until a significant portion of the motor unit (MU) pool is lost. Therefore, we performed more informative CMAP scans to study MU characteristics in a large cohort of patients with MMN. Methods We derived the maximum CMAP amplitude (CMAPmax), an MU number estimate (MUNE), and the largest MU amplitude stimulus current required to elicit 5%, 50%, and 95% of CMAPmax (S5, S50, S95) and relative ranges ([S95 − S5] × 100 / S50) from the scans. These metrics were compared with clinical, laboratory, and NCS results. Results Forty MMN patients and 24 healthy controls were included in the study. CMAPmax and MUNE were reduced in MMN patients (both P < .001). Largest MU amplitude as a percentage of CMAPmax was increased in MMN patients (P < .001). Disease duration and treatment duration were not associated with MUNE. Relative range was larger in patients with anti‐GM1 antibodies than in those without anti‐GM1 antibodies (P = .016) and controls (P < .001). The largest MU amplitudes were larger in patients without anti‐GM1 antibodies than in patients with anti‐GM1 antibodies (P = .037) and controls (P = .044). Discussion We found that MU loss is common in MMN and accompanied by enlarged MUs. Presence of anti‐GM1 antibodies was associated with increased relative range of MU thresholds and reduction in largest MU amplitude. Our findings indicate that CMAP scans complement routine NCS, and may have potential for practical monitoring of treatment efficacy and disease progression.
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Affiliation(s)
| | - Maria O Kovalchuk
- Department of Neurology, Brain Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H Stephan Goedee
- Department of Neurology, Brain Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Leonard J van Schelven
- Department of Medical Technology and Clinical Physics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology, Brain Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Hessel Franssen
- Department of Neurology, Brain Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Boudewijn T H M Sleutjes
- Department of Neurology, Brain Centre Utrecht, University Medical Centre Utrecht, Utrecht, The Netherlands
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van Rosmalen MHJ, Goedee HS, Derks R, Asselman F, Verhamme C, de Luca A, Hendrikse J, van der Pol WL, Froeling M. Quantitative magnetic resonance imaging of the brachial plexus shows specific changes in nerve architecture in chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy and motor neuron disease. Eur J Neurol 2021; 28:2716-2726. [PMID: 33934438 PMCID: PMC8362016 DOI: 10.1111/ene.14896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/12/2021] [Accepted: 04/28/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND The immunological pathophysiologies of chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN) differ considerably, but neither has been elucidated completely. Quantitative magnetic resonance imaging (MRI) techniques such as diffusion tensor imaging, T2 mapping, and fat fraction analysis may indicate in vivo pathophysiological changes in nerve architecture. Our study aimed to systematically study nerve architecture of the brachial plexus in patients with CIDP, MMN, motor neuron disease (MND) and healthy controls using these quantitative MRI techniques. METHODS We enrolled patients with CIDP (n = 47), MMN (n = 29), MND (n = 40) and healthy controls (n = 10). All patients underwent MRI of the brachial plexus and we obtained diffusion parameters, T2 relaxation times and fat fraction using an automated processing pipeline. We compared these parameters between groups using a univariate general linear model. RESULTS Fractional anisotropy was lower in patients with CIDP compared to healthy controls (p < 0.001), patients with MND (p = 0.010) and MMN (p < 0.001). Radial diffusivity was higher in patients with CIDP compared to healthy controls (p = 0.015) and patients with MND (p = 0.001) and MMN (p < 0.001). T2 relaxation time was elevated in patients with CIDP compared to patients with MND (p = 0.023). Fat fraction was lower in patients with CIDP and MMN compared to patients with MND (both p < 0.001). CONCLUSION Our results show that quantitative MRI parameters differ between CIDP, MMN and MND, which may reflect differences in underlying pathophysiological mechanisms.
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Affiliation(s)
- Marieke H. J. van Rosmalen
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtThe Netherlands
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - H. Stephan Goedee
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Rosina Derks
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Fay‐Lynn Asselman
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Camiel Verhamme
- Department of NeurologyAmsterdam NeuroscienceAmsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
| | - Alberto de Luca
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - J. Hendrikse
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - W. Ludo van der Pol
- Department of Neurology and NeurosurgeryBrain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Martijn Froeling
- Department of RadiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
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Cox SZ, Gwathmey KG. Chronic Immune-Mediated Polyneuropathies. Clin Geriatr Med 2021; 37:327-345. [PMID: 33858614 DOI: 10.1016/j.cger.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This article discusses the chronic immune-mediated polyneuropathies, a broad category of acquired polyneuropathies that encompasses chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), the most common immune-mediated neuropathy, the CIDP variants, and the vasculitic neuropathies. Polyneuropathies associated with rheumatological diseases and systemic inflammatory diseases, such as sarcoidosis, will also be briefly covered. These patients' history, examination, serum studies, and electrodiagnostic studies, as well as histopathological findings in the case of vasculitis, confirm the diagnosis and differentiate them from the more common length-dependent polyneuropathies. Prompt identification and initiation of treatment is imperative for these chronic immune-mediated polyneuropathies to prevent disability and even death.
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Affiliation(s)
- Stephen Zachary Cox
- Department of Neurology, Virginia Commonwealth University, 1101 East Marshall Street, PO Box 980599, Richmond, VA 23298, USA
| | - Kelly G Gwathmey
- Department of Neurology, Virginia Commonwealth University, 1101 East Marshall Street, PO Box 980599, Richmond, VA 23298, USA.
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Gwathmey K. Chronic Inflammatory Demyelinating Polyradiculoneuropathy and Its Variants. Continuum (Minneap Minn) 2020; 26:1205-1223. [PMID: 33002999 DOI: 10.1212/con.0000000000000907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and its variants comprise a group of immune-mediated neuropathies with distinctive clinical presentations and electrodiagnostic features. Prompt recognition of these treatable disorders is mandatory as delays result in significant disability and morbidity. This article highlights the clinical presentation, pathophysiology, diagnostic evaluation, and treatment approach of these polyneuropathies. RECENT FINDINGS The spectrum of CIDP is expanding with the recent characterization of neuropathies associated with nodal and paranodal antibodies. These neuropathies are distinguished by their unique presentations and are often refractory to IV immunoglobulin (IVIg) therapy. Subcutaneous immunoglobulins have recently been approved as a treatment option for CIDP and join corticosteroids, IVIg, and plasma exchange as first-line treatment. SUMMARY CIDP is characterized by progressive symmetric proximal and distal weakness, large fiber sensory loss, and areflexia, with clinical nadir reached more than 8 weeks after symptom onset. Autoimmune demyelinating neuropathies fall on a continuum, with differences in the type of nerve fibers affected and pattern of deficits. Distinguishing between typical CIDP and its variants allows for selection of the most appropriate treatment.
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Sleutjes BTHM, Kovalchuk MO, Durmus N, Buitenweg JR, van Putten MJAM, van den Berg LH, Franssen H. Simulating perinodal changes observed in immune-mediated neuropathies: impact on conduction in a model of myelinated motor and sensory axons. J Neurophysiol 2019; 122:1036-1049. [PMID: 31291151 DOI: 10.1152/jn.00326.2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Immune-mediated neuropathies affect myelinated axons, resulting in conduction slowing or block that may affect motor and sensory axons differently. The underlying mechanisms of these neuropathies are not well understood. Using a myelinated axon model, we studied the impact of perinodal changes on conduction. We extended a longitudinal axon model (41 nodes of Ranvier) with biophysical properties unique to human myelinated motor and sensory axons. We simulated effects of temperature and axonal diameter on conduction and strength-duration properties. We then studied effects of impaired nodal sodium channel conductance and paranodal myelin detachment by reducing periaxonal resistance, as well as their interaction, on conduction in the 9 middle nodes and enclosed paranodes. Finally, we assessed the impact of reducing the affected region (5 nodes) and adding nodal widening. Physiological motor and sensory conduction velocities and changes to axonal diameter and temperature were observed. The sensory axon had a longer strength-duration time constant. Reducing sodium channel conductance and paranodal periaxonal resistance induced progressive conduction slowing. In motor axons, conduction block occurred with a 4-fold drop in sodium channel conductance or a 7.7-fold drop in periaxonal resistance. In sensory axons, block arose with a 4.8-fold drop in sodium channel conductance or a 9-fold drop in periaxonal resistance. This indicated that motor axons are more vulnerable to developing block. A boundary of block emerged when the two mechanisms interacted. This boundary shifted in opposite directions for a smaller affected region and nodal widening. These differences may contribute to the predominance of motor deficits observed in some immune-mediated neuropathies.NEW & NOTEWORTHY Immune-mediated neuropathies may affect myelinated motor and sensory axons differently. By the development of a computational model, we quantitatively studied the impact of perinodal changes on conduction in motor and sensory axons. Simulations of increasing nodal sodium channel dysfunction and paranodal myelin detachment induced progressive conduction slowing. Sensory axons were more resistant to block than motor axons. This could explain the greater predisposition of motor axons to functional deficits observed in some immune-mediated neuropathies.
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Affiliation(s)
- Boudewijn T H M Sleutjes
- Department of Neurology, Brain Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria O Kovalchuk
- Department of Neurology, Brain Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Naric Durmus
- Biomedical Signals and Systems, MIRA, Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands.,Department of Clinical Neurophysiology, University of Twente, Enschede, The Netherlands
| | - Jan R Buitenweg
- Biomedical Signals and Systems, MIRA, Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Michel J A M van Putten
- Department of Clinical Neurophysiology, University of Twente, Enschede, The Netherlands.,Department of Neurology and Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology, Brain Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hessel Franssen
- Department of Neurology, Brain Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
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Goedee HS, Notermans NC, Visser LH, van Asseldonk JTH, Franssen H, Vrancken AFJE, Nikolakopoulos S, van den Berg LH, van der Pol WL. Neuropathy associated with immunoglobulin M monoclonal gammopathy: A combined sonographic and nerve conduction study. Muscle Nerve 2019; 60:263-270. [PMID: 31269243 PMCID: PMC6771847 DOI: 10.1002/mus.26626] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 06/27/2019] [Accepted: 06/29/2019] [Indexed: 12/13/2022]
Abstract
Introduction We assessed the specific sonographic pattern of structural nerve abnormalities in immunoglobulin M (IgM) neuropathy and disease controls. Methods We enrolled 106 incident patients—32 patients with IgM neuropathy, 42 treatment‐naive patients with chronic inflammatory demyelinating polyneuropathy, and 32 patients with axonal neuropathies. All patients underwent standardized ancillary testing in addition to standardized sonography of the brachial plexus and the large arm and leg nerves bilaterally. Results We found widespread nerve enlargement in IgM neuropathy and chronic inflammatory demyelinating polyneuropathy (CIDP), with specific enlargement of brachial plexus and proximal segments of median nerve but not in axonal disease controls (P < .001). Sonographic nerve hypertrophy in IgM neuropathy was not associated with nerve conduction, clinical, or laboratory characteristics. Discussion Immunoglobulin M neuropathy is characterized by widespread nerve enlargement indistinguishable from CIDP. Our data provide evidence to confirm that the disease process is not confined to the more distal parts of nerves in either classical demyelinating or axonal variants of neuropathy with associated IgM.
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Affiliation(s)
- H Stephan Goedee
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicolette C Notermans
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leo H Visser
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | | | - Hessel Franssen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexander F J E Vrancken
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stavros Nikolakopoulos
- Department of Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W Ludo van der Pol
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Physiology of Myelinated Nerve Conduction and Pathophysiology of Demyelination. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1190:85-106. [DOI: 10.1007/978-981-32-9636-7_7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
PURPOSE OF REVIEW This article provides a conceptual framework for the evaluation of patients with suspected polyneuropathy to enhance the clinician's ability to localize and confirm peripheral nervous system pathology and, when possible, identify an etiologic diagnosis through use of rational clinical and judicious testing strategies. RECENT FINDINGS Although these strategies are largely time-honored, recent insights pertaining to the pathophysiology of certain immune-mediated neuropathies and to evolving genetic testing strategies may modify the way that select causes of neuropathy are conceptualized, evaluated, and managed. SUMMARY The strategies suggested in this article are intended to facilitate accurate bedside diagnosis in patients with suspected polyneuropathy and allow efficient and judicious use of supplementary testing and application of rational treatment when indicated.
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Sleutjes BT, Drenthen J, Boskovic E, van Schelven LJ, Kovalchuk MO, Lumens PG, van den Berg LH, Franssen H. Excitability tests using high-density surface-EMG: A novel approach to studying single motor units. Clin Neurophysiol 2018; 129:1634-1641. [DOI: 10.1016/j.clinph.2018.04.754] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 04/19/2018] [Accepted: 04/29/2018] [Indexed: 12/13/2022]
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Svahn J, Petiot P, Antoine JC, Vial C, Delmont E, Viala K, Steck AJ, Magot A, Cauquil C, Zarea A, Echaniz-Laguna A, Iancu Ferfoglia R, Gueguen A, Magy L, Léger JM, Kuntzer T, Ferraud K, Lacour A, Camdessanché JP. Anti-MAG antibodies in 202 patients: clinicopathological and therapeutic features. J Neurol Neurosurg Psychiatry 2018; 89:499-505. [PMID: 29070644 DOI: 10.1136/jnnp-2017-316715] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the clinicopathological and therapeutic features of patients with low (≥1000 to <10 000 Bühlmann Titre Units) (BTU), medium (10 000-70 000) or high (≥70 000) anti-myelin-associated glycoprotein (anti-MAG) antibody titres. METHODS We retrospectively and prospectively analysed standardised report forms and medical records of 202 patients from 14 neuromuscular centres. RESULTS Mean age at onset and mean time between symptom onset to last follow-up were respectively 62.6 years (25-91.4) and 8.4 years (0.3-33.3). Anti-MAG antibody titres at diagnosis were low, medium or high in 11%, 51% and 38% of patients. Patients presented with monoclonal gammopathy of undetermined significance in 68% of cases. About 17% of patients presented with 'atypical' clinical phenotype independently of anti-MAG titres, including acute or chronic sensorimotor polyradiculoneuropathies (12.4%), and asymmetric or multifocal neuropathy (3%). At the most severe disease stage, 22.4% of patients were significantly disabled. Seventy-eight per cent of patients received immunotherapies. Transient clinical worsening was observed in 12% of patients treated with rituximab (11/92). Stabilisation after rituximab treatment during the 7-12-month follow-up period was observed in 29% of patients. Clinical response to rituximab during the 6-month and/or 7-12-month follow-up period was observed in 31.5% of patients and correlated with anti-MAG titre ≥10 000 BTU. CONCLUSION Our study highlights the extended clinical spectrum of patients with anti-MAG neuropathy, which appears unrelated to antibody titre. Besides, it may also suggest beneficial use of rituximab in the early phase of anti-MAG neuropathy.
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Affiliation(s)
- Juliette Svahn
- Electroneuromyography and Neuromuscular Department, University Hospital Lyon, Lyon, France
| | - Philippe Petiot
- Electroneuromyography and Neuromuscular Department, University Hospital Lyon, Lyon, France
| | | | - Christophe Vial
- Electroneuromyography and Neuromuscular Department, University Hospital Lyon, Lyon, France
| | - Emilien Delmont
- Department of Neurology, University Hospital Timone, Marseille, France
| | - Karine Viala
- Department of Neurophysiology and Neuropathology, University Hospital Pitié-Salpêtrière, Paris, France
| | - Andreas J Steck
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Armelle Magot
- Neuromuscular Reference Center, University Hospital Nantes, Nantes, France
| | - Cecile Cauquil
- Department of Neurology, University Hospital Bicêtre, Le Kremlin Bicêtre, France
| | - Aline Zarea
- Neuromuscular Competence Center, University Hospital Rouen, Rouen, France
| | | | - Ruxandra Iancu Ferfoglia
- Electroneuromyography and Neuromuscular Disorders Unit, University Hospital Geneva, Geneva, Switzerland
| | - Antoine Gueguen
- Department of Neurology, Fondation Ophtalmologique A. de Rothschild, Paris, France
| | - Laurent Magy
- Department of Neurology, University Hospital Limoges, Limoges, France
| | - Jean-Marc Léger
- Department of Neurology, University Hospital Pitié-Salpêtrière, Paris, France
| | - Thierry Kuntzer
- Department of Clinical Neurosciences, Nerve-Muscle Unit, Neurology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Karine Ferraud
- Department of Neurology, University Hospital Saint-Etienne, Saint-Etienne, France
| | - Arnaud Lacour
- Department of Neurology, University Hospital Saint-Etienne, Saint-Etienne, France
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Lizarraga AA, Cochrane TI, Berkowitz AL. Improvement of distal acquired demyelinating symmetric (DADS) neuropathy after exposure to factor Xa inhibitor. J Neurol Sci 2018; 388:146-149. [DOI: 10.1016/j.jns.2018.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 02/25/2018] [Accepted: 03/07/2018] [Indexed: 11/16/2022]
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14
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Kovalchuk MO, Franssen H, Van Schelven LJ, Sleutjes BTHM. Comparing excitability at 37°C versus at 20°C: Differences between motor and sensory axons. Muscle Nerve 2017; 57:574-580. [DOI: 10.1002/mus.25960] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Maria O. Kovalchuk
- Department of Neurology and Neurosurgery, Brain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht The Netherlands
| | - Hessel Franssen
- Department of Neurology and Neurosurgery, Brain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht The Netherlands
| | - Leonard J. Van Schelven
- Department of Medical Technology and Clinical PhysicsUniversity Medical Center UtrechtUtrecht the Netherlands
| | - Boudewijn T. H. M. Sleutjes
- Department of Neurology and Neurosurgery, Brain Center Rudolf MagnusUniversity Medical Center UtrechtUtrecht The Netherlands
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Österlund-Tauriala E, Partanen JV. Three cases of acute distal demyelinating neuropathy with recovery. Clin Case Rep 2017; 5:822-828. [PMID: 28588819 PMCID: PMC5457988 DOI: 10.1002/ccr3.943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 08/23/2016] [Accepted: 03/02/2017] [Indexed: 11/10/2022] Open
Abstract
Guillain–Barré syndrome (GBS) may present as distal acute inflammatory demyelinating polyradiculoneuropathy (AIDP), with severe distal demyelination of the peripheral nerves in the absence of radiculitis. Clinical course is benign, and prognosis seems favorable, but nerve conduction studies (NCS) findings at nadir may resemble some chronic forms of polyneuropathy, so close follow‐up during recovery is needed.
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Affiliation(s)
- Emilia Österlund-Tauriala
- Clinical Neurosciences, Neurology Helsinki University Hospital University of Helsinki Helsinki Finland
| | - Juhani V Partanen
- Clinical Neurosciences, Clinical Neurophysiology Helsinki University Hospital University of Helsinki Helsinki Finland
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Dyer WB, Tan JCG, Day T, Kiers L, Kiernan MC, Yiannikas C, Reddel S, Ng K, Mondy P, Dennington PM, Dean MM, Trist HM, Dos Remedios C, Hogarth PM, Vucic S, Irving DO. Immunomodulation of inflammatory leukocyte markers during intravenous immunoglobulin treatment associated with clinical efficacy in chronic inflammatory demyelinating polyradiculoneuropathy. Brain Behav 2016; 6:e00516. [PMID: 27781132 PMCID: PMC5064330 DOI: 10.1002/brb3.516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 04/28/2016] [Accepted: 05/21/2016] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The objective of the study was to profile leukocyte markers modulated during intravenous immunoglobulin (IVIg) treatment, and to identify markers and immune pathways associated with clinical efficacy of IVIg for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) with potential for monitoring treatment efficacy. METHODS Response to IVIg treatment in newly diagnosed IVIg-naïve and established IVIg-experienced patients was assessed by changes in expression of inflammatory leukocyte markers by flow cytometry. The adjusted INCAT disability and Medical Research Council sum scores defined clinical response. RESULTS Intravenous immunoglobulin modulated immunopathogenic pathways associated with inflammatory disease in CIDP. Leukocyte markers of clinical efficacy included reduced CD185+ follicular helper T cells, increased regulatory markers (CD23 and CD72) on B cells, and reduction in the circulating inflammatory CD16+ myeloid dendritic cell (mDC) population and concomitant increase in CD62L and CD195 defining a less inflammatory lymphoid homing mDC phenotype. A decline in inflammatory CD16+ dendritic cells was associated with clinical improvement or stability, and correlated with magnitude of improvement in neurological assessment scores, but did not predict relapse. IVIg also induced a nonspecific improvement in regulatory and reduced inflammatory markers not associated with clinical response. CONCLUSIONS Clinically effective IVIg modulated inflammatory and regulatory pathways associated with ongoing control or resolution of CIDP disease. Some of these markers have potential for monitoring outcome.
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Affiliation(s)
- Wayne B Dyer
- Australian Red Cross Blood Service Alexandria NSW Australia; Sydney Medical School University of Sydney Camperdown NSW Australia
| | - Joanne C G Tan
- Australian Red Cross Blood Service Alexandria NSW Australia; Sydney Medical School University of Sydney Camperdown NSW Australia
| | - Timothy Day
- Cabrini Medical Centre Cabrini Hospital Malvern Vic. Australia; Department of Neurophysiology Royal Melbourne Hospital Parkville Vic. Australia
| | - Lynette Kiers
- Department of Neurophysiology Royal Melbourne Hospital Parkville Vic. Australia
| | - Matthew C Kiernan
- Sydney Medical School University of Sydney Camperdown NSW Australia; Brain and Mind Centre University of Sydney Camperdown NSW Australia
| | | | - Stephen Reddel
- Sydney Medical School University of Sydney Camperdown NSW Australia; Department of Neurology Concord Repatriation and General Hospital Concord NSW Australia
| | - Karl Ng
- Sydney Medical School University of Sydney Camperdown NSW Australia; Department of Neurophysiology Royal North Shore Hospital St Leonards NSW Australia
| | - Phillip Mondy
- Australian Red Cross Blood Service Alexandria NSW Australia
| | | | - Melinda M Dean
- Australian Red Cross Blood Service Kelvin Grove Qld Australia
| | | | | | | | - Steve Vucic
- Sydney Medical School University of Sydney Camperdown NSW Australia; Department of Neurology Westmead Hospital Westmead NSW Australia
| | - David O Irving
- Australian Red Cross Blood Service Alexandria NSW Australia; University of Technology Sydney NSW Australia
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17
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Haakma W, Jongbloed BA, Froeling M, Goedee HS, Bos C, Leemans A, van den Berg LH, Hendrikse J, van der Pol WL. MRI shows thickening and altered diffusion in the median and ulnar nerves in multifocal motor neuropathy. Eur Radiol 2016; 27:2216-2224. [PMID: 27655303 PMCID: PMC5374174 DOI: 10.1007/s00330-016-4575-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 08/09/2016] [Accepted: 08/22/2016] [Indexed: 12/13/2022]
Abstract
Objectives To study disease mechanisms in multifocal motor neuropathy (MMN) with magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI) of the median and ulnar nerves. Methods We enrolled ten MMN patients, ten patients with amyotrophic lateral sclerosis (ALS) and ten healthy controls (HCs). Patients underwent MRI (in a prone position) and nerve conduction studies. DTI and fat-suppressed T2-weighted scans of the forearms were performed on a 3.0T MRI scanner. Fibre tractography of the median and ulnar nerves was performed to extract diffusion parameters: fractional anisotropy (FA), mean (MD), axial (AD) and radial (RD) diffusivity. Cross-sectional areas (CSA) were measured on T2-weighted scans. Results Forty-five out of 60 arms were included in the analysis. AD was significantly lower in MMN patients (2.20 ± 0.12 × 10-3 mm2/s) compared to ALS patients (2.31 ± 0.17 × 10-3 mm2/s; p < 0.05) and HCs (2.31± 0.17 × 10-3 mm2/s; p < 0.05). Segmental analysis showed significant restriction of AD, RD and MD (p < 0.005) in the proximal third of the nerves. CSA was significantly larger in MMN patients compared to ALS patients and HCs (p < 0.01). Conclusions Thickening of nerves is compatible with changes in the myelin sheath structure, whereas lowered AD values suggest axonal dysfunction. These findings suggest that myelin and axons are diffusely involved in MMN pathogenesis. Key Points • Diffusion magnetic resonance imaging provides quantitative information about multifocal motor neuropathy (MMN). • Diffusion tensor imaging allows non-invasive evaluation of the forearm nerves in MMN. • Nerve thickening and lowered diffusion parameters suggests myelin and axonal changes. • This study can help to provide insight into pathological mechanisms of MMN. Electronic supplementary material The online version of this article (doi:10.1007/s00330-016-4575-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wieke Haakma
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands. .,Department of Forensic Medicine and Comparative Medicine Lab, Aarhus University, Aarhus, Denmark.
| | - Bas A Jongbloed
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martijn Froeling
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H Stephan Goedee
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Clemens Bos
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexander Leemans
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W Ludo van der Pol
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
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18
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Marrali G, Salamone P, Casale F, Fuda G, Cugnasco P, Caorsi C, Amoroso A, Calvo A, Lopiano L, Cocito D, Chiò A. NADPH oxidase 2 (NOX2) enzyme activation in patients with chronic inflammatory demyelinating polyneuropathy. Eur J Neurol 2016; 23:958-63. [DOI: 10.1111/ene.12971] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 01/18/2016] [Indexed: 11/28/2022]
Affiliation(s)
- G. Marrali
- ‘Rita Levi Montalcini’ Department of Neuroscience; University of Torino; Torino Italy
| | - P. Salamone
- ‘Rita Levi Montalcini’ Department of Neuroscience; University of Torino; Torino Italy
| | - F. Casale
- ‘Rita Levi Montalcini’ Department of Neuroscience; University of Torino; Torino Italy
| | - G. Fuda
- ‘Rita Levi Montalcini’ Department of Neuroscience; University of Torino; Torino Italy
| | - P. Cugnasco
- ‘Rita Levi Montalcini’ Department of Neuroscience; University of Torino; Torino Italy
| | - C. Caorsi
- Immunogenetics and Transplant Biology Laboratory; Department of Medical Sciences; University of Torino; Torino Italy
| | - A. Amoroso
- Immunogenetics and Transplant Biology Laboratory; Department of Medical Sciences; University of Torino; Torino Italy
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza; Torino Italy
| | - A. Calvo
- ‘Rita Levi Montalcini’ Department of Neuroscience; University of Torino; Torino Italy
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza; Torino Italy
| | - L. Lopiano
- ‘Rita Levi Montalcini’ Department of Neuroscience; University of Torino; Torino Italy
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza; Torino Italy
| | - D. Cocito
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza; Torino Italy
| | - A. Chiò
- ‘Rita Levi Montalcini’ Department of Neuroscience; University of Torino; Torino Italy
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza; Torino Italy
- Institute of Cognitive Sciences and Technologies; Consiglio nazionale delle Ricerche; Rome Italy
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19
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Pitarokoili K, Schlamann M, Kerasnoudis A, Gold R, Yoon MS. Comparison of clinical, electrophysiological, sonographic and MRI features in CIDP. J Neurol Sci 2015; 357:198-203. [DOI: 10.1016/j.jns.2015.07.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/26/2015] [Accepted: 07/21/2015] [Indexed: 12/29/2022]
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20
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Franssen H. Relation between symptoms and pathophysiology in inflammatory neuropathies: Controversies and hypotheses. Neurosci Lett 2015; 596:84-9. [PMID: 25483620 DOI: 10.1016/j.neulet.2014.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 11/11/2014] [Accepted: 12/02/2014] [Indexed: 10/24/2022]
Abstract
This review attempts to explain the symptoms experienced by patients with inflammatory neuropathies by pathophysiological events. The emphasis is not on the primary events that may cause a particular illness but on downstream events taking place in peripheral nerves or muscles. Symptoms that will be discussed include sensory predominance, motor predominance, activity-induced weakness, heat paresis, and cold paresis. Each symptom is associated with, but not limited to, particular neuropathies.
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Affiliation(s)
- Hessel Franssen
- Brain Center Rudolf Magnus, Section Neuromuscular Disorders, Department of Neurology F02.230, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, Netherlands.
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21
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Berger M, Allen JA. Optimizing IgG therapy in chronic autoimmune neuropathies: a hypothesis driven approach. Muscle Nerve 2015; 51:315-26. [PMID: 25418426 PMCID: PMC4357394 DOI: 10.1002/mus.24526] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 12/22/2022]
Abstract
Prolonged intravenous immunoglobulin (IVIG) therapy is used for the chronic autoimmune neuropathies chronic idiopathic demyelinating polyneuropathy and multifocal motor neuropathy, but the doses and treatment intervals are usually chosen empirically due to a paucity of data from dose-response studies. Recent studies of the electrophysiology and immunology of these diseases suggest that antibody-induced reversible dysfunction of nodes of Ranvier may play a role in conduction block and disability which responds to immunotherapy more rapidly than would be expected for demyelination or axonal damage per se. Clinical reports suggest that in some cases, the effects of each dose of IVIG may be transient, wearing-off before the next dose is due. These observations lead us to hypothesize that that therapeutic IgG acts by competing with pathologic autoantibodies and that individual patients may require different IgG levels for optimal therapeutic effects. Frequent IVIG dosing and weekly subcutaneous IgG have been tried as ways of continuously maintaining high serum IgG levels, resulting in stabilization of neuromuscular function in small case series. Frequent grip strength and disability measurements, performed by the patient at home and reported electronically, can be used to assess the extent and duration of responses to IgG doses. Individualization of IgG treatment regimens may optimize efficacy, minimize disability, and identify nonresponders.
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Affiliation(s)
- Melvin Berger
- CSL Behring, LLC., 1040 First Avenue, King of PrussiaPennsylvania, USA 19406
| | - Jeffrey A Allen
- University of MinnesotaMinneapolis, Minnesota, USA
- Northwestern UniversityChicago, Illinois, USA
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22
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Kuntzer T. [2013: what's new in inflammatory neuropathies]. Rev Neurol (Paris) 2014; 170:850-3. [PMID: 25459118 DOI: 10.1016/j.neurol.2014.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 04/27/2014] [Accepted: 05/14/2014] [Indexed: 11/19/2022]
Abstract
Several high-quality publications were published in 2013 and some major trials studies were started. In Guillain-Barré syndrome, events included the launch of IGOS and a better understanding of diagnostic limits, the effect of influenza vaccination, and better care, but uncertainty remains about analgesics. A new mouse model was also described. In chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), diagnostic pitfalls can be recalled. Our knowledge of underlying pathophysiological processes has improved, and the value of monitoring with function and deficit scores has been demonstrated. IVIG can sometimes be effective longer than expected, but CIDP remains sensitive to corticosteroids, particularly with the long-term beneficial effects of megadose dexamethasone. The impact of fingolimod remains to be demonstrated in an ongoing trial. Advances concerning multifocal motor neuropathy, inflammatory plexopathy, and neuropathy with anti -MAG activity are discussed but treatments already recognized as effective should not be changed. Imaging of peripheral nerve progresses.
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Affiliation(s)
- T Kuntzer
- Département des neurosciences cliniques, université de Lausanne, CHU Vaudois (CHUV), BH07/413, rue du Bugnon 46, 1011 Lausanne, Suisse.
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23
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Svahn J, Antoine JC, Camdessanché JP. Pathophysiology and biomarkers in chronic inflammatory demyelinating polyradiculoneuropathies. Rev Neurol (Paris) 2014; 170:808-17. [PMID: 25459126 DOI: 10.1016/j.neurol.2014.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired dysimmune disorder characterized by strong heterogeneity in terms of clinical manifestations, prognostic and response to treatment. To date, its pathophysiology and potential target antigens are not totally identified despite substantial progress in the understanding of the involved molecular mechanisms. Recent researches in the field have underlined the importance of cell-mediated immunity (lymphocytesT CD4+, CD8+ and macrophages), the breakdown of blood-nerve barrier, a failure of T-cell regulation, and the disruption of nodal and paranodal organization at the node of Ranvier. This last point is possibly mediated by autoantibodies towards axoglial adhesion molecules which may disrupt sodium and potassium voltage-gated channels clustering leading to a failure of saltatory conduction and the apparition of conduction blocks. The purpose of this article is to overview the main pathophysiologic mechanisms and biomarkers identified in CIDP.
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Affiliation(s)
- J Svahn
- Inserm 1028 CNRS UMR5292, équipe neuro-oncologie neuro-inflammation, faculté de médecine Jacques-Lisfranc, 42023 Saint-Étienne cedex 2, France; Université Claude-Bernard Lyon 1, 69003 Lyon, France
| | - J-C Antoine
- Inserm 1028 CNRS UMR5292, équipe neuro-oncologie neuro-inflammation, faculté de médecine Jacques-Lisfranc, 42023 Saint-Étienne cedex 2, France; Service de neurologie, hôpital Nord, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 02, France; Centre référent maladies neuromusculaires rares Rhône-Alpes, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 02, France
| | - J-P Camdessanché
- Inserm 1028 CNRS UMR5292, équipe neuro-oncologie neuro-inflammation, faculté de médecine Jacques-Lisfranc, 42023 Saint-Étienne cedex 2, France; Service de neurologie, hôpital Nord, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 02, France; Centre référent maladies neuromusculaires rares Rhône-Alpes, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 02, France.
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24
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Franssen H. The Node of Ranvier in Multifocal Motor Neuropathy. J Clin Immunol 2014; 34 Suppl 1:S105-11. [DOI: 10.1007/s10875-014-0023-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/19/2014] [Indexed: 01/07/2023]
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25
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Harschnitz O, Jongbloed BA, Franssen H, Straver DCG, van der Pol WL, van den Berg LH. MMN: from immunological cross-talk to conduction block. J Clin Immunol 2014; 34 Suppl 1:S112-9. [PMID: 24728842 PMCID: PMC4050293 DOI: 10.1007/s10875-014-0026-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/19/2014] [Indexed: 12/11/2022]
Abstract
Multifocal motor neuropathy (MMN) is a rare inflammatory neuropathy characterized by progressive, asymmetric distal limb weakness and conduction block (CB). Clinically MMN is a pure motor neuropathy, which as such can mimic motor neuron disease. GM1-specific IgM antibodies are present in the serum of approximately half of all MMN patients, and are thought to play a key role in the immune pathophysiology. Intravenous immunoglobulin (IVIg) treatment has been shown to be effective in MMN in five randomized placebo-controlled trials. Despite long-term treatment with intravenous immunoglobulin (IVIg), which is efficient in the majority of patients, slowly progressive axonal degeneration and subsequent muscle weakness cannot be fully prevented. In this review, we will discuss the current understanding of the immune pathogenesis underlying MMN and how this may cause CB, available treatment strategies and future therapeutic targets.
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Affiliation(s)
- Oliver Harschnitz
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center Rudolf Magnus, Utrecht, 3584 CG, The Netherlands
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