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Anand A, Hildebrandt CC, Shenoy V, Sutherland RW. Novel CHRNA3 variants identified in a patient with bladder dysfunction, dysautonomia, and gastrointestinal dysmotility. Am J Med Genet A 2024; 194:e63526. [PMID: 38192228 DOI: 10.1002/ajmg.a.63526] [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: 10/16/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/10/2024]
Abstract
Congenital anomalies of the kidney and urinary tract (CAKUT) are estimated to be responsible for 20%-50% of congenital anomalies and are also a leading etiology of early-onset renal disease. Primary CAKUT are caused by genetic factors that impair proper in-utero genitourinary tract development and secondary CAKUT result from the influence of environmental factors. The CHRNA3 gene, which encodes the Alpha-3 subunit of the nicotinic acetylcholine receptor, is hypothesized to be associated with Megacystis-microcolon-intestinal hyperperistalsis syndrome. More recently, pathogenic variants in CHRNA3 have been identified in individuals with CAKUT as well as individuals with panautonomic failure. Here we present a patient with neurogenic bladder, vesicoureteral reflux, mydriasis, and gastrointestinal dysmotility found to have novel compound heterozygous variants in CHRNA3. These findings support the consideration of CHRNA3 disruption in the differential for CAKUT with dysautonomia and gastrointestinal dysmotility.
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Affiliation(s)
- Asha Anand
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Clara C Hildebrandt
- UNC School of Medicine, Chapel Hill, North Carolina, USA
- UNC Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Vivek Shenoy
- UNC School of Medicine, Chapel Hill, North Carolina, USA
- UNC Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Richard W Sutherland
- UNC School of Medicine, Chapel Hill, North Carolina, USA
- UNC Department of Urology, UNC School of Medicine, Chapel Hill, North Carolina, USA
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2
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Nakane S, Koike H, Hayashi T, Nakatsuji Y. Autoimmune Autonomic Neuropathy: From Pathogenesis to Diagnosis. Int J Mol Sci 2024; 25:2296. [PMID: 38396973 PMCID: PMC10889307 DOI: 10.3390/ijms25042296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
Autoimmune autonomic ganglionopathy (AAG) is a disease of autonomic failure caused by ganglionic acetylcholine receptor (gAChR) autoantibodies. Although the detection of autoantibodies is important for distinguishing the disease from other neuropathies that present with autonomic dysfunction, other factors are important for accurate diagnosis. Here, we provide a comprehensive review of the clinical features of AAG, highlighting differences in clinical course, clinical presentation, and laboratory findings from other neuropathies presenting with autonomic symptoms. The first step in diagnosing AAG is careful history taking, which should reveal whether the mode of onset is acute or chronic, followed by an examination of the time course of disease progression, including the presentation of autonomic and extra-autonomic symptoms. AAG is a neuropathy that should be differentiated from other neuropathies when the patient presents with autonomic dysfunction. Immune-mediated neuropathies, such as acute autonomic sensory neuropathy, are sometimes difficult to differentiate, and therefore, differences in clinical and laboratory findings should be well understood. Other non-neuropathic conditions, such as postural orthostatic tachycardia syndrome, chronic fatigue syndrome, and long COVID, also present with symptoms similar to those of AAG. Although often challenging, efforts should be made to differentiate among the disease candidates.
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Affiliation(s)
- Shunya Nakane
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Haruki Koike
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga 849-8501, Japan
| | - Tomohiro Hayashi
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Yuji Nakatsuji
- Department of Neurology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
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Villagrán-García M, Farina A, Campetella L, Arzalluz-Luque J, Honnorat J. Autonomic nervous system involvement in autoimmune encephalitis and paraneoplastic neurological syndromes. Rev Neurol (Paris) 2024; 180:107-116. [PMID: 38142198 DOI: 10.1016/j.neurol.2023.12.001] [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: 09/11/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/25/2023]
Abstract
In autoimmune neurological diseases, the autonomic nervous system can be the primary target of autoimmunity (e.g. autoimmune autonomic ganglionopathy), or, more frequently, be damaged together with other areas of the nervous system (e.g. Guillain-Barré syndrome). Patients with autoimmune encephalitis and paraneoplastic neurological syndromes (PNS) often develop dysautonomia; however, the frequency and spectrum of autonomic signs and symptoms remain ill defined except for those scenarios in which dysautonomia is a core feature of the disease. Such is the case of Lambert-Eaton myasthenic syndrome, Morvan syndrome or anti-NMDAR encephalitis; in the latter, patients with dysautonomia have been reported to carry a more severe disease and to retain higher disability than those without autonomic dysfunction. Likewise, the presence of autonomic involvement indicates a higher risk of death due to neurological cause in patients with anti-Hu PNS. However, in anti-Hu and other PNS, as well as in the context of immune checkpoint inhibitors' toxicities, the characterization of autonomic involvement is frequently overshadowed by the severity of other neurological symptoms and signs. When evaluated with tests specific for autonomic function, patients with autoimmune encephalitis or PNS usually show a more widespread autonomic involvement than clinically suggested, which may reflect a potential gap of care when it comes to diagnosing dysautonomia. This review aims to revise the autonomic involvement in patients with autoimmune encephalitis and PNS, using for that purpose an antibody-based approach. We also discuss and provide general recommendations for the evaluation and management of dysautonomia in these patients.
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Affiliation(s)
- M Villagrán-García
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France
| | - A Farina
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France; Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence, Italy
| | - L Campetella
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France
| | - J Arzalluz-Luque
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - J Honnorat
- French Reference Centre on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, hôpital neurologique, Bron, France; Inserm U1314, MeLiS-UCBL-CNRS UMR 5284, University Claude-Bernard Lyon 1, Lyon, France.
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Pechlivanidou M, Ninou E, Karagiorgou K, Tsantila A, Mantegazza R, Francesca A, Furlan R, Dudeck L, Steiner J, Tzartos J, Tzartos S. Autoimmunity to Neuronal Nicotinic Acetylcholine Receptors. Pharmacol Res 2023; 192:106790. [PMID: 37164280 DOI: 10.1016/j.phrs.2023.106790] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 04/30/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
Nicotinic acetylcholine receptors (nAChRs) are widely expressed in many and diverse cell types, participating in various functions of cells, tissues and systems. In this review, we focus on the autoimmunity against neuronal nAChRs, the specific autoantibodies and their mechanisms of pathological action in selected autoimmune diseases. We summarize the current relevant knowledge from human diseases as well as from experimental models of autoimmune neurological disorders related to antibodies against neuronal nAChR subunits. Despite the well-studied high immunogenicity of the muscle nAChRs where autoantibodies are the main pathogen of myasthenia gravis, autoimmunity to neuronal nAChRs seems infrequent, except for the autoantibodies to the ganglionic receptor, the α3 subunit containing nAChR (α3-nAChR), which are detected and are likely pathogenic in Autoimmune Autonomic Ganglionopathy (AAG). We describe the detection, presence and function of these antibodies and especially the recent development of a cell-based assay (CBA) which, contrary to until recently available assays, is highly specific for AAG. Rare reports of autoantibodies to the other neuronal nAChR subtypes include a few cases of antibodies to α7 and/or α4β2 nAChRs in Rasmussen encephalitis, schizophrenia, autoimmune meningoencephalomyelitis, and in some myasthenia gravis patients with concurrent CNS symptoms. Neuronal-type nAChRs are also present in several non-excitable tissues, however the presence and possible role of antibodies against them needs further verification. It is likely that the future development of more sensitive and disease-specific assays would reveal that neuronal nAChR autoantibodies are much more frequent and may explain the mechanisms of some seronegative autoimmune diseases.
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Affiliation(s)
| | | | - Katerina Karagiorgou
- Tzartos NeuroDiagnostics, Athens, Greece; Department of Biochemistry and Biotechnology, University of Thessaly, Larissa, Greece
| | | | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Andreetta Francesca
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Rozzano, Milan, Italy; Clinical and Research Center - IRCCS, Humanitas University, Rozzano, Milan, Italy
| | - Leon Dudeck
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Johann Steiner
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; Center for Behavioral Brain Sciences (CBBS), Magdeburg, Germany; Center for Health and Medical Prevention (CHaMP), Magdeburg, Germany; German Center for Mental Health DZPG, Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health C-I-R-C, Halle-Jena-Magdeburg, Germany
| | - John Tzartos
- 2(nd) Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece.
| | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece; Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece; Department of Pharmacy, University of Patras, Patras, Greece.
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Younger DS. Autonomic failure: Clinicopathologic, physiologic, and genetic aspects. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:55-102. [PMID: 37562886 DOI: 10.1016/b978-0-323-98818-6.00020-0] [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
Over the past century, generations of neuroscientists, pathologists, and clinicians have elucidated the underlying causes of autonomic failure found in neurodegenerative, inherited, and antibody-mediated autoimmune disorders, each with pathognomonic clinicopathologic features. Autonomic failure affects central autonomic nervous system components in the α-synucleinopathy, multiple system atrophy, characterized clinically by levodopa-unresponsive parkinsonism or cerebellar ataxia, and pathologically by argyrophilic glial cytoplasmic inclusions (GCIs). Two other central neurodegenerative disorders, pure autonomic failure characterized clinically by deficits in norepinephrine synthesis and release from peripheral sympathetic nerve terminals; and Parkinson's disease, with early and widespread autonomic deficits independent of the loss of striatal dopamine terminals, both express Lewy pathology. The rare congenital disorder, hereditary sensory, and autonomic neuropathy type III (or Riley-Day, familial dysautonomia) causes life-threatening autonomic failure due to a genetic mutation that results in loss of functioning baroreceptors, effectively separating afferent mechanosensing neurons from the brain. Autoimmune autonomic ganglionopathy caused by autoantibodies targeting ganglionic α3-acetylcholine receptors instead presents with subacute isolated autonomic failure affecting sympathetic, parasympathetic, and enteric nervous system function in various combinations. This chapter is an overview of these major autonomic disorders with an emphasis on their historical background, neuropathological features, etiopathogenesis, diagnosis, and treatment.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Association of Cardiac Autonomic Responses with Clinical Outcomes of Myasthenia Gravis: Short-Term Analysis of the Heart-Rate and Blood Pressure Variability. J Clin Med 2022; 11:jcm11133697. [PMID: 35806988 PMCID: PMC9267657 DOI: 10.3390/jcm11133697] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: The aim of the study was to assess cardiac and autonomic function in patients with myasthenia gravis (MG) and to explore its relationship with disease outcomes. Methods: Thirty-eight patients with an MG were enrolled (median age 40.5 years; median disease duration 5.5 years). Cardiovascular parameters, baroreflex sensitivity (BRS), spectral indices of short-term heart rate (HRV), and systolic blood pressure variability (SBPV) were compared with age- and gender-matched controls (n = 30). Cardiac autonomic function was assessed during the response to standing (tilt) and deep breathing tests (expiration/inspiration ratio-E/I). Results: HR and BP responses to the tilt test were similar in both groups. MG patients, as compared to controls, were characterized by altered SBPV at rest, significantly reduced HR response to the deep breathing test (p < 0.001), increased sympathovagal balance after tilt (delta LF/HF-RRI, p = 0.037), and lower values of BRS (p = 0.007) and hemodynamic parameters, i.e., cardiac index, index contractility, left ventricular work index, at rest and during tilt. There was no association between disease duration and autonomic parameters. Disease severity, as determined by MGFA (Myasthenia Gravis Foundation of America) corrected for age and sex, was an independent predictor of diminished vagal tone (E/I ratio) and increased sympathetic response to tilt (delta LF/HF-RRI) as measured with HRV. Lower BRS was associated with greater disease severity and older age. Hemodynamic parameters were predominantly predicted by age and sex. Conclusion: Our results confirm cardiac autonomic dysfunction among MG patients with predominant parasympathetic impairment. Clinicians should consider evaluation of autonomic balance in MG patients with, or at risk for, cardiovascular disease.
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Zhang J, Huang X, Shi Q. Autonomic dysfunction detected by skin sympathetic response in Lambert-Eaton myasthenic syndrome: a case report. BMC Neurol 2022; 22:106. [PMID: 35305594 PMCID: PMC8933941 DOI: 10.1186/s12883-022-02625-1] [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: 09/29/2021] [Accepted: 03/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Lambert-Eaton myasthenic syndrome (LEMS) is a type of paraneoplastic syndrome that may initially manifest itself with proximal weakness and gait abnormalities. Approximately up to 50% of LEMS patients have a primary autonomic dysfunction. Case presentation We present here a case of a 75-year-old male with symmetric proximal muscle weakness, dry mouth and constipation. The cutaneous response to scratch and upright tilt-table testing were positive. A repetitive nerve stimulation test showed that there was a decremental response of compound muscle action potential (CMAP) amplitude at 3 Hz while an incremental response at 20 Hz. The presence of antibodies against voltage-gated calcium channels (VGCC) confirmed the diagnosis. Because of the prominent symptom of autonomic disorder, the patient further underwent the test of skin sympathetic response (SSR). Lower amplitude and longer response duration were found in palms, while it evoked no response in soles. Conclusions In this case, we present the detailed results of SSR test on a patient suffering LEMS with autonomic disorder. Since autonomic dysfunction has a significant impact on clinical management and SSR test is an effective detection method, we recommend that SSR test be performed on patients with LEMS regularly.
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Norcliffe-Kaufmann L. Stress and the baroreflex. Auton Neurosci 2022; 238:102946. [PMID: 35086020 DOI: 10.1016/j.autneu.2022.102946] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/16/2021] [Accepted: 01/16/2022] [Indexed: 11/27/2022]
Abstract
The stress response to emotions elicits the release of glucocorticoids from the adrenal cortex, epinephrine from the adrenal medulla, and norepinephrine from the sympathetic nerves. The baroreflex adapts to buffer these responses to ensure that perfusion to the organs meets the demands while maintaining blood pressure within a within a narrow range. While stressor-evoked autonomic cardiovascular responses may be adaptive for the short-term, the recurrent exaggerated cardiovascular stress reactions can be maladaptive in the long-term. Prolonged stress or loss of the baroreflex's buffering capacity can predispose episodes of heightened sympathetic activity during stress leading to hypertension, tachycardia, and ventricular wall motion abnormalities. This review discusses 1) how the baroreflex responds to acute and chronic stressors, 2) how lesions in the neuronal pathways of the baroreflex alter the ability to respond or counteract the stress response, and 3) the techniques to assess baroreflex sensitivity and stress responses. Evidence suggests that loss of baroreflex sensitivity may predispose heightened autonomic responses to stress and at least in part explain the association between stress, mortality and cardiovascular diseases.
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Autoimmune autonomic ganglionopathy: Ganglionic acetylcholine receptor autoantibodies. Autoimmun Rev 2021; 21:102988. [PMID: 34728435 DOI: 10.1016/j.autrev.2021.102988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/28/2021] [Indexed: 11/24/2022]
Abstract
Autoimmune Autonomic Ganglionopathy (AAG) is a rare immune-mediated disease of the autonomic nervous system. The incidence of AAG is unknown and diagnosis is often difficult due to the multicompartmental nature of the autonomic nervous system - sympathetic, parasympathetic and enteric components - with variable severity and number of components affected. Diagnostic confidence is increased when ganglionic acetylcholine receptor (gnACHR) autoantibodies are detected. Three gnACHR autoantibody diagnostic assays have been described (two binding assays, one receptor immunomodulation assay), but cross-validation between assays is limited. The prevalence of gnACHR autoantibodies in AAG is not known, with application of different clinical and laboratory criteria in the few studies of AAG cohorts and large retrospective laboratory studies of positive gnACHR autoantibodies lacking adequate clinical characterisation. Furthermore, the rate of unexpected gnACHR autoantibody positivity in conditions without overt autonomic dysfunction (false positive results) adds to the complexity of their interpretation. We review the pathophysiology of gnACHR autoantibodies and assays for their detection, with immunomodulation and high titer radioimmunoprecipitation results likely offering better AAG disease identification.
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Bryarly M, Raj SR, Phillips L, Hynan LS, Okamoto LE, Arnold AC, Paranjape SY, Vernino M, Black BK, Vernino S. Ganglionic Acetylcholine Receptor Antibodies in Postural Tachycardia Syndrome. Neurol Clin Pract 2021; 11:e397-e401. [PMID: 34484936 DOI: 10.1212/cpj.0000000000001047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/10/2020] [Indexed: 01/21/2023]
Abstract
Objective Postural tachycardia syndrome (POTS), the most common form of dysautonomia, may be associated with autoimmunity in some cases. Autoantibodies against the ganglionic acetylcholine receptor (gAChR) have been reported in a minority of patients with POTS, but the prevalence and clinical relevance is unclear. Methods Clinical information and serum samples were systematically collected from participants with POTS and healthy control volunteers (n = 294). The level of positive gAChR antibodies was classified as very low (0.02-0.05 nmol/L), low (0.05-0.2 nmol/L), and high (>0.2 nmol/L). Results Fifteen of 217 patients with POTS (7%) had gAChR antibodies (8 very low and 7 low). Six of the 77 healthy controls (8%) were positive (3 very low and 3 low). There were no clinical differences between seropositive and seronegative patients with POTS. Conclusions Prevalence of gAChR antibody did not differ between POTS and healthy controls, and none had high antibody levels. Patients with POTS were not clinically different based on seropositivity. Low levels of gAChR antibodies are not clinically important in POTS.
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Affiliation(s)
- Meredith Bryarly
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Satish R Raj
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Lauren Phillips
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Linda S Hynan
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Luis E Okamoto
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Amy C Arnold
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Sachin Y Paranjape
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Megan Vernino
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Bonnie K Black
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
| | - Steven Vernino
- Department of Neurology (MB, LP, MV, SV), UT Southwestern Medical Center, Dallas; Autonomic Dysfunction Center (SRR, LEO, ACA, SYP, BKB), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Neural & Behavioral Sciences (ACA), Pennsylvania State University College of Medicine, Hershey; Department of Cardiac Sciences (SRR), Libin Cardiovascular Institute of Alberta, University of Calgary, Canada; and Departments of Population & Data Sciences and Psychiatry (LSH), UT Southwestern Medical Center, Dallas
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Autoimmune Gastrointestinal Dysmotility in a Patient With HIV Treated With Methylprednisolone and Pyridostigmine. ACG Case Rep J 2021; 8:e00636. [PMID: 34307714 PMCID: PMC8294874 DOI: 10.14309/crj.0000000000000636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/30/2021] [Indexed: 11/17/2022] Open
Abstract
Primary autoimmune gastrointestinal dysmotility is a limited form of autoimmune dysautonomia, driven by antiganglionic autoantibodies (AGAs) against enteric neurons. AGAs are observed in other autoimmune diseases, such as Guillain-Barré syndrome, before the development onset of gastrointestinal symptoms. Here, we report a case of a 57-year-old woman with human immunodeficiency virus, who previously developed Guillain-Barré syndrome, presenting with 6 months of intestinal dysmotility. Diagnosis was made by detecting AGAs to ganglionic acetylcholine receptor, alpha-3 subunit, radiographic evidence of duodenal dysmotility, and exclusion of other causes. The patient received high-dose methylprednisolone with low-dose pyridostigmine, which led to significant improvement of symptoms.
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12
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Stauffer C, Llano DA, Kitten S. Nicotinic ganglionic acetylcholine receptor autoantibodies associated with paraneoplastic disease in a neuropsychiatric patient. BMJ Case Rep 2021; 14:14/5/e240824. [PMID: 34045196 DOI: 10.1136/bcr-2020-240824] [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: 11/04/2022] Open
Abstract
Nicotinic ganglionic acetylcholine receptor autoantibodies (alpha-3-AChR Ab) are associated with paraneoplastic syndromes when present in low elevations. These antibodies can be tested for as part of an autoimmune encephalopathy panel in neuropsychiatric patients; a mildly elevated titre of alpha-3-AChR Ab that may start as an incidental finding can lead to the diagnosis of a previously undetected cancer. While alpha-3-AChR Ab are most typically associated with thymomas and small cell lung cancer, the presence of these antibodies can suggest a diverse range of other cancers. This case presents a patient with longstanding neuropsychiatric symptoms and possible functional hypothyroidism for whom a low elevation in alpha-3-AChR Ab led to the finding of papillary thyroid carcinoma.
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Affiliation(s)
- Catherine Stauffer
- Carle Foundation Hospital, Urbana, Illinois, USA .,Carle Illinois College of Medicine, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Daniel A Llano
- Carle Neuroscience Institute, Carle Foundation Hospital, Urbana, Illinois, USA
| | - Suzanna Kitten
- Psychiatry, Carle Foundation Hospital, Urbana, Illinois, USA
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Liou YT, Wei JCC, Hu KC, Hung YM, Chou MC, Chang R. Risk of subsequent atrial fibrillation in patients with myasthenia gravis: A population-based cohort study. Medicine (Baltimore) 2021; 100:e26008. [PMID: 34011098 PMCID: PMC8137031 DOI: 10.1097/md.0000000000026008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 05/01/2021] [Indexed: 01/05/2023] Open
Abstract
The purpose of this study was to explore the association between myasthenia gravis (MG) and the risk of atrial fibrillation (AF) in an Asian population. The risk was analyzed in a cohort of 5528 patients with history of MG and 5528 individuals without MG using a hospitalization claim dataset. Both groups were matched by age, sex, index year and baseline comorbidities as an original analysis. A Cox proportional hazard model was used to estimate the hazard ratio and 95% confidence interval of AF after adjusting for demographic and relevant clinical covariates. The adjusted hazard ratio of the MG group compared with that of the non-MG group was 1.03 (95% confidence interval, 0.76-1.38) for AF. A stratified analysis showed that compared with the propensity score matched non-MG group, there was no increased risk of developing AF based on age categories, gender, or comorbidities. Different time follow-up periods results showed no increased risk of AF compared with the non-MG group. Overall, in the Taiwanese cohort, MG is not associated with an increased risk of AF.
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Affiliation(s)
- Yaw-Tzeng Liou
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital
- Institute of Medicine, Chung Shan Medical University
- Graduate Institute of Integrated Medicine, China Medical University
| | - Kai-Chieh Hu
- Management office for Health Data, China Medical University Hospital, Taichung
| | - Yao-Min Hung
- Department of Internal Medicine, Kaohsiung Municipal United Hospital, Kaohsiung
- College of Health and Nursing, Meiho University
| | - Mei-Chia Chou
- Department of Recreation and Sports Management, Tajen University
- Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Pingtung Branch, Pingtung County, Taiwan
| | - Renin Chang
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
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Rzepiński Ł, Zawadka-Kunikowska M, Newton JL, Zalewski P. Cardiac Autonomic Dysfunction in Myasthenia Gravis and Relapsing-Remitting Multiple Sclerosis-A Pilot Study. J Clin Med 2021; 10:2173. [PMID: 34069830 PMCID: PMC8157285 DOI: 10.3390/jcm10102173] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 12/21/2022] Open
Abstract
This study assessed cardiac autonomic response to head-up tilt test (HUTT) in 23 myasthenia gravis (MG) and 23 relapsing-remitting multiple sclerosis (RRMS) patients compared to 30 healthy controls (HC). Task Force® Monitor was used to evaluate cardiac inotropy parameters, baroreflex sensitivity (BRS), heart rate (HRV), and blood pressure variability (BPV) during HUTT. MG patients were characterized by reduced BRS (p < 0.05), post-HUTT decrease in high-frequency component (p < 0.05) and increase in sympathovagal ratio of HRV (p < 0.05) when compared to controls indicating parasympathetic deficiency with a shift of sympathovagal balance toward sympathetic predominance. Compared to HC, MG patients also showed lower cardiac inotropy parameters, specifically, left ventricular work index (LVWI) during supine rest (p < 0.05) as well as LVWI and cardiac index values in response to orthostatic stress (p < 0.01 and p < 0.05, respectively). Compared to controls, RRMS patients were characterized by lower HRV delta power spectral density (p < 0.05) and delta low-frequency HRV (p < 0.05) in response to HUTT suggesting combined sympathetic and parasympathetic dysfunction. There were no differences in cardiac autonomic parameters between MG and MS patients (p > 0.05). Our study highlights the possibility of cardiac and autonomic dysfunction in patients with MG and RRMS which should be considered in the pharmacological and rehabilitation approach to managing these conditions.
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Affiliation(s)
- Łukasz Rzepiński
- Department of Neurology, 10th Military Research Hospital and Polyclinic, Powstańców Warszawy 5, 85-681 Bydgoszcz, Poland
| | - Monika Zawadka-Kunikowska
- Department of Hygiene, Epidemiology, Ergonomy and Postgraduate Education, Ludwik Rydygier Collegium Medicum in Bydgoszcz Nicolaus Copernicus University in Torun, M. Sklodowskiej-Curie 9, 85-094 Bydgoszcz, Poland; (M.Z.-K.); (P.Z.)
| | - Julia L. Newton
- Population Health Science Institute, The Medical School, Newcastle University, Framlington Place, Newcastle-upon-Tyne NE2 4HH, UK;
| | - Paweł Zalewski
- Department of Hygiene, Epidemiology, Ergonomy and Postgraduate Education, Ludwik Rydygier Collegium Medicum in Bydgoszcz Nicolaus Copernicus University in Torun, M. Sklodowskiej-Curie 9, 85-094 Bydgoszcz, Poland; (M.Z.-K.); (P.Z.)
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15
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Nicotinic Acetylcholine Receptor Involvement in Inflammatory Bowel Disease and Interactions with Gut Microbiota. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031189. [PMID: 33572734 PMCID: PMC7908252 DOI: 10.3390/ijerph18031189] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022]
Abstract
The gut-brain axis describes a complex interplay between the central nervous system and organs of the gastrointestinal tract. Sensory neurons of dorsal root and nodose ganglia, neurons of the autonomic nervous system, and immune cells collect and relay information about the status of the gut to the brain. A critical component in this bi-directional communication system is the vagus nerve which is essential for coordinating the immune system’s response to the activities of commensal bacteria in the gut and to pathogenic strains and their toxins. Local control of gut function is provided by networks of neurons in the enteric nervous system also called the ‘gut-brain’. One element common to all of these gut-brain systems is the expression of nicotinic acetylcholine receptors. These ligand-gated ion channels serve myriad roles in the gut-brain axis including mediating fast synaptic transmission between autonomic pre- and postganglionic neurons, modulation of neurotransmitter release from peripheral sensory and enteric neurons, and modulation of cytokine release from immune cells. Here we review the role of nicotinic receptors in the gut-brain axis with a focus on the interplay of these receptors with the gut microbiome and their involvement in dysregulation of gut function and inflammatory bowel diseases.
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Abstract
PURPOSE OF REVIEW Cardiovascular autonomic dysfunction (AD) among cancer survivors is increasingly being recognized. However, the mechanisms and incidence are poorly understood. In this review, the clinical features, diagnostic modalities, proposed mechanisms, and currently available treatments of cardiovascular AD in cancer survivors are described. RECENT FINDINGS Much of our current understanding of cardiovascular AD is based on disease states such as diabetes, multisystem atrophy, and Parkinson's disease. Several non-invasive tests, measurements, and scoring systems have been developed as surrogates for autonomic function, with some even demonstrating associations with all-cause mortality. The mechanism of cardiovascular AD specifically in the cancer population, however, has not been directly studied. The etiology of cardiovascular AD in cancer survivors is likely multifactorial, and proposed mechanisms include direct nerve damage by chemoradiation, the pro-inflammatory state associated with malignancy, and paraneoplastic syndromes. It may also be that cardiovascular AD is an early marker of global cardiomyopathy rather than its own condition. Current pharmacologic options for cardiovascular AD are extrapolated from how it has been treated in other disease processes, and these agents have not been studied in the cancer population or compared head-to-head. Cardiovascular AD in cancer survivors can cause significant debilitation and may be associated with all-cause mortality. Current diagnostic modalities have several limitations, such as standardization and validity. However, given the nonspecific nature of cardiovascular AD, these tools provide an objective marker for diagnosis and tracking treatment response. While the mechanism of cardiovascular AD in cancer survivors has not been directly studied, it may be useful to evoke mechanisms of cardiovascular AD in other disease states such as diabetes, Parkinson's disease, and multisystem atrophy in addition to identifying unique conditions associated with malignancy like a pro-inflammatory state. Until further studies are performed, management of cardiovascular AD as seen in other disease states may serve as a guide for symptom management in cancer survivors.
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Cheshire WP, Freeman R, Gibbons CH, Cortelli P, Wenning GK, Hilz MJ, Spies JM, Lipp A, Sandroni P, Wada N, Mano A, Ah Kim H, Kimpinski K, Iodice V, Idiáquez J, Thaisetthawatkul P, Coon EA, Low PA, Singer W. Electrodiagnostic assessment of the autonomic nervous system: A consensus statement endorsed by the American Autonomic Society, American Academy of Neurology, and the International Federation of Clinical Neurophysiology. Clin Neurophysiol 2020; 132:666-682. [PMID: 33419664 DOI: 10.1016/j.clinph.2020.11.024] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 11/02/2020] [Accepted: 11/28/2020] [Indexed: 12/17/2022]
Abstract
Evaluation of disorders of the autonomic nervous system is both an art and a science, calling upon the physician's most astute clinical skills as well as knowledge of autonomic neurology and physiology. Over the last three decades, the development of noninvasive clinical tests that assess the function of autonomic nerves, the validation and standardization of these tests, and the growth of a large body of literature characterizing test results in patients with autonomic disorders have equipped clinical practice further with a valuable set of objective tools to assist diagnosis and prognosis. This review, based on current evidence, outlines an international expert consensus set of recommendations to guide clinical electrodiagnostic autonomic testing. Grading and localization of autonomic deficits incorporates scores from sympathetic cardiovascular adrenergic, parasympathetic cardiovagal, and sudomotor testing, as no single test alone is sufficient to diagnose the degree or distribution of autonomic failure. The composite autonomic severity score (CASS) is a useful score of autonomic failure that is normalized for age and gender. Valid indications for autonomic testing include generalized autonomic failure, regional or selective system syndromes of autonomic impairment, peripheral autonomic neuropathy and ganglionopathy, small fiber neuropathy, orthostatic hypotension, orthostatic intolerance, syncope, neurodegenerative disorders, autonomic hyperactivity, and anhidrosis.
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Affiliation(s)
- William P Cheshire
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, Florida 32224, USA
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, 330 Brookline Avenue, Boston, Massachusetts 02215-5400, USA
| | - Christopher H Gibbons
- Department of Neurology, Harvard Medical School, 330 Brookline Avenue, Boston, Massachusetts 02215-5400, USA
| | - Pietro Cortelli
- DIBINEM - University of Bologna, Bologna, Italy; IRCCS Istituto di Scienze Neurologiche, Bologna, Italy
| | - Gregor K Wenning
- Section of Clinical Neurobiology, Department of Neurology, Medical University of Innsbruck, Anichstraße 35, A-6020 Innsbruck, Austria
| | - Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Judith M Spies
- Department of Neurology, Level 8 East, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia
| | - Axel Lipp
- Park-Klinik Weißensee, Schönstraße 80, Berlin 13086, Germany
| | - Paola Sandroni
- Department of Neurology, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905, USA
| | - Naoki Wada
- Department of Renal and Urologic Surgery, Asahikawa Medical University, 2-1-1-1 Midorigaoka Higashi, Asahikawa 078-8510, Japan
| | - Akiko Mano
- Department of Cardiothoracic Surgery, Tokyo Metropolitan Geriatric Hospital, 35-2 Sakae-Cho Itabashi-ku, Tokyo 173-0015, Japan
| | - Hyun Ah Kim
- Department of Neurology, Keimyung University Dongsan Hospital, 2800 Dalgubeol Daero, Dalseo-gu, Daegu, South Korea
| | - Kurt Kimpinski
- School of Kinesiology, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, University Hospital, London Health Sciences Centre, London, Ontario, Canada; Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Valeria Iodice
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, Queen Square, Division of Clinical Neurology, Institute of Neurology, University College London, WC1N 3BG London, United Kingdom
| | - Juan Idiáquez
- Department of Neurologia, Facultad de Medicina, University of Valparaíso, 7 Norte 1122, Valparaíso, 2531094, Chile
| | - Pariwat Thaisetthawatkul
- Department of Neurological Sciences, 988435 University of Nebraska Medical Center, Omaha, Nebraska 68198-8435, USA
| | - Elizabeth A Coon
- Department of Neurology, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905, USA
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905, USA.
| | - Wolfgang Singer
- Department of Neurology, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905, USA.
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18
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Abstract
PURPOSE OF THE REVIEW This article reviews the anatomic, functional, and neurochemical organization of the sympathetic and parasympathetic outputs; the effects on target organs; the central mechanisms controlling autonomic function; and the pathophysiologic basis for core symptoms of autonomic failure. RECENT FINDINGS Functional neuroimaging studies have elucidated the areas involved in central control of autonomic function in humans. Optogenetic and other novel approaches in animal experiments have provided new insights into the role of these areas in autonomic control across behavioral states, including stress and the sleep-wake cycle. SUMMARY Control of the function of the sympathetic, parasympathetic, and enteric nervous system functions depends on complex interactions at all levels of the neuraxis. Peripheral sympathetic outputs are critical for maintenance of blood pressure, thermoregulation, and response to stress. Parasympathetic reflexes control lacrimation, salivation, pupil response to light, beat-to-beat control of the heart rate, gastrointestinal motility, micturition, and erectile function. The insular cortex, anterior and midcingulate cortex, and amygdala generate autonomic responses to behaviorally relevant stimuli. Several nuclei of the hypothalamus generate coordinated patterns of autonomic responses to internal or social stressors. Several brainstem nuclei participate in integrated control of autonomic function in relationship to respiration and the sleep-wake cycle. Disorders affecting the central or peripheral autonomic pathways, or both, manifest with autonomic failure (including orthostatic hypotension, anhidrosis, gastrointestinal dysmotility, and neurogenic bladder or erectile dysfunction) or autonomic hyperactivity, primary hypertension, tachycardia, and hyperhidrosis.
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19
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Yamakawa M, Mukaino A, Kimura A, Nagasako Y, Kitazaki Y, Maeda Y, Higuchi O, Takamatsu K, Watari M, Yoshikura N, Ikawa M, Sugimoto I, Sakurai Y, Matsuo H, Ando Y, Shimohata T, Nakane S. Antibodies to the α3 subunit of the ganglionic-type nicotinic acetylcholine receptors in patients with autoimmune encephalitis. J Neuroimmunol 2020; 349:577399. [PMID: 32980672 DOI: 10.1016/j.jneuroim.2020.577399] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 01/17/2023]
Abstract
Since autonomic dysfunction is closely associated with autoimmune encephalitis (AE), the objective of this study was to determine the autonomic symptoms and the prevalence of anti-α3 subunit of the ganglionic-type nicotinic acetylcholine receptor (gAChRα3) antibodies in the patients with AE. We reviewed the clinical features of 19 AE patients, and specifically analyzed sera for anti-gAChRα3 antibodies using the luciferase immunoprecipitation system (LIPS) assay. Cardiovascular autonomic symptoms were found to be common in patients with AE, and hypersalivation was seen only in patients with NMDAR encephalitis. LIPS detected anti-gAChRα3 antibodies in the sera from patients with AE (5/29, 26%). This study is the first to demonstrate that clinical characteristics including autonomic symptoms of AE patients with seropositivity for gAChR autoantibodies. It will be important to verify the role of gAChR antibodies in autonomic dysfunction and brain symptoms to clarify the pathogenesis of AE.
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Affiliation(s)
- Makoto Yamakawa
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Akihiro Mukaino
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuki Nagasako
- Department of Neurology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yuki Kitazaki
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yasushi Maeda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Osamu Higuchi
- Department of Neurology, National Hospital Organization Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Koutaro Takamatsu
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Mari Watari
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Nobuaki Yoshikura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masamichi Ikawa
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Izumi Sugimoto
- Department of Neurology, Mitsui Memorial Hospital, Tokyo, Japan
| | | | - Hidenori Matsuo
- Department of Neurology, National Hospital Organization Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shunya Nakane
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan.
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20
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Eom S, Kim C, Yeom HD, Lee J, Lee S, Baek YB, Na J, Park SI, Kim GY, Lee CM, Lee JH. Molecular Regulation of α3β4 Nicotinic Acetylcholine Receptors by Lupeol in Cardiovascular System. Int J Mol Sci 2020; 21:E4329. [PMID: 32570692 PMCID: PMC7352637 DOI: 10.3390/ijms21124329] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 11/20/2022] Open
Abstract
Cardiovascular disease (CVD) occurs globally and has a high mortality rate. The highest risk factor for developing CVD is high blood pressure. Currently, natural products are emerging for the treatment of hypertension to avoid the side effects of drugs. Among existing natural products, lupeol is known to be effective against hypertension in animal experiments. However, there exists no study regarding the molecular physiological evidence against the effects of lupeol. Consequently, we investigated the interaction of lupeol with α3β4 nicotinic acetylcholine receptors (nAChRs). In this study, we performed a two-electrode voltage-clamp technique to investigate the effect of lupeol on the α3β4 nicotine acetylcholine receptor using the oocytes of Xenopus laevis. Coapplication of acetylcholine and lupeol inhibited the activity of α3β4 nAChRs in a concentration-dependent, voltage-independent, and reversible manner. We also conducted a mutational experiment to investigate the influence of residues of the α3 and β4 subunits on lupeol binding with nAChRs. Double mutants of α3β4 (I37A/N132A), nAChRs significantly attenuated the inhibitory effects of lupeol compared to wild-type α3β4 nAChRs. A characteristic of α3β4 nAChRs is their effect on transmission in the cardiac sympathetic ganglion. Overall, it is hypothesized that lupeol lowers hypertension by mediating its effects on α3β4 nAChRs. The interaction between lupeol and α3β4 nAChRs provides evidence against its effect on hypertension at the molecular-cell level. In conclusion, the inhibitory effect of lupeol is proposed as a novel therapeutic approach involving the antihypertensive targeting of α3β4 nAChRs. Furthermore, it is proposed that the molecular basis of the interaction between lupeol and α3β4 nAChRs would be helpful in cardiac-pharmacology research and therapeutics.
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Affiliation(s)
- Sanung Eom
- Department of Biotechnology, Chonnam National University, Gwangju 61886, Korea; (S.E.); (C.K.); (H.D.Y.); (J.L.); (S.L.) (J.N.)
| | - Chaelin Kim
- Department of Biotechnology, Chonnam National University, Gwangju 61886, Korea; (S.E.); (C.K.); (H.D.Y.); (J.L.); (S.L.) (J.N.)
| | - Hye Duck Yeom
- Department of Biotechnology, Chonnam National University, Gwangju 61886, Korea; (S.E.); (C.K.); (H.D.Y.); (J.L.); (S.L.) (J.N.)
| | - Jaeeun Lee
- Department of Biotechnology, Chonnam National University, Gwangju 61886, Korea; (S.E.); (C.K.); (H.D.Y.); (J.L.); (S.L.) (J.N.)
| | - Shinhui Lee
- Department of Biotechnology, Chonnam National University, Gwangju 61886, Korea; (S.E.); (C.K.); (H.D.Y.); (J.L.); (S.L.) (J.N.)
| | - Yeong-Bin Baek
- College of Veterinary Medicine, Chonnam National University, Gwangju 61186, Korea; (Y.-B.B.); (S.-I.P.)
| | - Jinseong Na
- Department of Biotechnology, Chonnam National University, Gwangju 61886, Korea; (S.E.); (C.K.); (H.D.Y.); (J.L.); (S.L.) (J.N.)
| | - Sang-Ik Park
- College of Veterinary Medicine, Chonnam National University, Gwangju 61186, Korea; (Y.-B.B.); (S.-I.P.)
| | - Gye-Yeop Kim
- Department of Physical Therapy, Dongshin University, Naju 58245, Korea;
| | - Chang-Min Lee
- College of Veterinary Medicine, Chonnam National University, Gwangju 61186, Korea; (Y.-B.B.); (S.-I.P.)
| | - Jun-Ho Lee
- Department of Biotechnology, Chonnam National University, Gwangju 61886, Korea; (S.E.); (C.K.); (H.D.Y.); (J.L.); (S.L.) (J.N.)
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21
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Saberi F, Bahrami F, Saberi M, Mashhadi Akbar Boojar M. The pro-convulsant effects of diazinon low dose in male rats under amygdala kindling. Drug Chem Toxicol 2020; 45:625-632. [PMID: 32249606 DOI: 10.1080/01480545.2020.1746801] [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: 10/24/2022]
Abstract
Organophosphates can damage the brain in systemic intoxication. In this study, the effects of a minimum toxic dose (MTD) of diazinon (DZ) on amygdala afterdischarge threshold (ADT), kindling acquisition and kindled seizure parameters were evaluated. Intact male rats were stereotactically implanted with a tripolar and two monopolar electrodes in the amygdala and dura respectively. After recovery, animals received daily either, olive oil (control), 15 or 30 mg/kg (MTD) of DZ intraperitoneally, and ADT, afterdischarge duration (ADD) at each stage (S1 to S5) of kindling and number of trials for kindling acquisition were determined daily. Also, the effect of DZ on stage 4 latency (S4L), ADD, stage 5 duration (S5D) and the activity of the red blood cholinesterase (ChE) were evaluated. The ADT was lower and the ADD was longer significantly in DZ treated group in comparison to control (p < 0.01) and the number of trials to reach each stage of kindling acquisition was reduced (p < 0.001). The total amount of ADDs during the kindling procedure increased significantly 5 days after DZ treatment. While the S4L was reduced, the S5D increased significantly after DZ treatment. The ChE activity was inhibited significantly after 20 min of DZ treatment and continued till 24 h (p < 0.01). Data indicate that even half of the MTD of DZ could increase the sensitivity and excitability of the CNS to the epileptic activity at least via reduction of stimulation threshold and AD prolongation. Furthermore, repeated exposure to the low concentrations of organophosphates may be pro-convulsant and should be restricted.
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Affiliation(s)
- Fatemeh Saberi
- Department of Dermatology, Razi Skin Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farideh Bahrami
- Department of Physiology and Biophysics, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mehdi Saberi
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran, Iran.,Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mahdi Mashhadi Akbar Boojar
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran, Iran.,Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
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22
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Ganglionic Acetylcholine Receptor Antibodies and Autonomic Dysfunction in Autoimmune Rheumatic Diseases. Int J Mol Sci 2020; 21:ijms21041332. [PMID: 32079137 PMCID: PMC7073227 DOI: 10.3390/ijms21041332] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/13/2020] [Accepted: 02/13/2020] [Indexed: 12/12/2022] Open
Abstract
Autonomic neuropathy has been reported in autoimmune rheumatic diseases (ARD) including Sjögren’s syndrome, systemic sclerosis, rheumatoid arthritis, and systemic lupus erythematosus. However, the pathophysiological mechanism underlying autonomic dysfunction remains unknown to researchers. On the other hand, autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder, which causes dysautonomia that is mediated by autoantibodies against ganglionic acetylcholine receptors (gAChRs). The purpose of this review was to describe the characteristics of autonomic disturbance through previous case reports and the functional tests used in these studies and address the importance of anti-gAChR antibodies. We have established luciferase immunoprecipitation systems to detect antibodies against gAChR in the past and determined the prevalence of gAChR antibodies in various autoimmune diseases including AAG and rheumatic diseases. Autonomic dysfunction, which affects lower parasympathetic and higher sympathetic activity, is usually observed in ARD. The anti-gAChR antibodies may play a crucial role in autonomic dysfunction observed in ARD. Further studies are necessary to determine whether anti-gAChR antibody levels are correlated with the severity of autonomic dysfunction in ARD.
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23
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Nakane S. [Autoimmune autonomic ganglionopathy]. Rinsho Shinkeigaku 2019; 59:783-790. [PMID: 31761837 DOI: 10.5692/clinicalneurol.cn-001354] [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] [Indexed: 06/10/2023]
Abstract
Autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder of widespread autonomic failure. Approximately half of the patients with AAG have the autoantibodies against the neuronal nicotinic acetylcholine receptor (AChR) in autonomic ganglia. These ganglionic AChR antibodies have the potential to mediate the synaptic transmission in sympathetic, parasympathetic, and enteric ganglia. Therefore, seropositive AAG patients exhibit various autonomic symptoms. Extra-autonomic manifestations (coexistence with brain involvement, sensory disturbance, endocrine disorders, autoimmune diseases and tumors) are present in many patients with AAG. The nicotinic AChRs comprise a family of abundantly expressed ligand-gated cation channels found throughout the central and peripheral nervous systems. Moreover, limited manifestations of autoimmune dysautonomia including autoimmune gastrointestinal dysmotility are newly recognized clinical entity. Although combined immunomodulatory therapy is beneficial for almost all patients with AAG, several case reports of some AAG patients with small benefit exist. This review focuses on the recent progress in the clinical approaches of AAG and its related disorders involving the role of autoantibodies and clinical practice.
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Affiliation(s)
- Shunya Nakane
- Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital
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Gao CA, Weber UM, Peixoto AJ, Weiss SA. Seronegative autoimmune autonomic ganglionopathy from dual immune checkpoint inhibition in a patient with metastatic melanoma. J Immunother Cancer 2019; 7:262. [PMID: 31623673 PMCID: PMC6796437 DOI: 10.1186/s40425-019-0748-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 09/20/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors have improved clinical outcomes including survival in several malignancies but have also been associated with a range of immune-related adverse events (irAEs). Neurological irAEs are rare compared to the more typical skin, gastrointestinal, and endocrine toxicities, and are often underrecognized and challenging to diagnose. Here, we report a case of seronegative autoimmune autonomic ganglionopathy (AAG) induced by dual immune checkpoint inhibitor therapy (ICI) in a patient with metastatic melanoma. CASE PRESENTATION A patient with metastatic melanoma was treated with ipilimumab and nivolumab. He developed a constellation of new symptoms including nausea, fatigue, and severe orthostatic hypotension refractory to fluid resuscitation. An infectious, cardiac, neurologic, and endocrine workup were unrevealing. Cardiovascular autonomic testing revealed poor sympathetic nervous system responses. He was diagnosed with seronegative AAG and significantly improved with immunomodulatory therapies including IVIG and steroids as well as varying doses of midodrine and fludrocortisone. He was able to restart nivolumab without recurrence of his symptoms. However, the AAG reoccurred when he was re-challenged with ipilimumab and nivolumab due to disease progression. While the AAG was manageable with steroids at that time, unfortunately his melanoma became resistant to ICI. CONCLUSIONS Immune checkpoint inhibitors can have a wide range of unusual, rare irAEs, including neurotoxicity such as AAG. Clinicians should maintain suspicion for this toxicity so that treatment can be rapidly provided to avoid disability.
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Affiliation(s)
- Catherine A Gao
- Department of Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Urs M Weber
- Department of Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Aldo J Peixoto
- Department of Medicine (Nephrology), Yale University School of Medicine, 330 Cedar Street, Boardman 114, New Haven, CT, 06520, USA
| | - Sarah A Weiss
- Department of Medicine (Medical Oncology), Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA.
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Blackburn KM, Kubiliun M, Harris S, Vernino S. Neurological autoimmune disorders with prominent gastrointestinal manifestations: A review of presentation, evaluation, and treatment. Neurogastroenterol Motil 2019; 31:e13611. [PMID: 31016817 DOI: 10.1111/nmo.13611] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/19/2019] [Accepted: 04/10/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The identification of autoantibodies directed against neuronal antigens has led to the recognition of a wide spectrum of neurological autoimmune disorders (NAD). With timely recognition and treatment, many patients with NAD see rapid improvement. Symptoms associated with NAD can be diverse and are determined by the regions of the nervous system affected. In addition to neurological symptoms, a number of these disorders present with prominent gastrointestinal (GI) manifestations such as nausea, diarrhea, weight loss, and gastroparesis prompting an initial evaluation by gastroenterologists. PURPOSE This review provides a general overview of autoantibodies within the nervous system, focusing on three scenarios in which nervous system autoimmunity may initially present with gut symptoms. A general approach to evaluation and treatment, including antibody testing, will be reviewed.
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Affiliation(s)
- Kyle M Blackburn
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Maddie Kubiliun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samar Harris
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Steven Vernino
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
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Bouxin M, Schvartz B, Mestrallet S, Debrumetz A, Hentzien M, Tabary T, Cohen R, Nicolas G, Bani-Sadr F. Rituximab treatment in seronegative autoimmune autonomic neuropathy and autoimmune autonomic ganglionopathy: Case-report and literature review. J Neuroimmunol 2018; 326:28-32. [PMID: 30468952 DOI: 10.1016/j.jneuroim.2018.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/13/2018] [Accepted: 11/13/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Autoimmune autonomic ganglionopathy (AAG) is a rare disease with no well-established treatment. Until recently, AAG could be seropositive (50 to 60% of patients) or seronegative for ganglionic (α3-type) nicotinic acetylcholine receptor (Gα3NAChR) antibodies. In early 2018, the two forms of the disease were distinguished, separating seropositive from seronegative ones, designating this latter form "seronegative autoimmune autonomic neuropathy" (SAAN). Most described treatments are plasma exchange (PE) and intravenous immunoglobulin (IVIG). However in some cases with no or small benefit, other immunomodulatory therapies, such as rituximab have been reported. We report the case of a 24-year-old female patient successfully treated for SAAN with rituximab and steroids after IVIG and PE failure. We also provide a review of case-reports reporting rituximab treatment for both SAAN and AAG. METHODS To identify articles reporting SAAN and AAG treatment with rituximab, we searched the PubMed database using the terms "autoimmune autonomic ganglionopathy", "autoimmune autonomic neuropathy" or "seronegative autoimmune autonomic neuropathy" and "rituximab". RESULTS Including our patient, nine cases have been described in the literature (4 SAAN and 5 AAG). Rituximab had a significant positive effect in 2 out of 4 SAAN and all 5 AAG cases, used alone or in association with other etiologic treatments. CONCLUSION Our study suggests rituximab (alone or in association with other treatments) could provide efficacy in both SAAN and AAG when PE and/or IVIG are not effective enough.
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Affiliation(s)
- M Bouxin
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - B Schvartz
- Department of Nephrology and Transplantation, Reims Teaching Hospitals, Reims, France
| | - S Mestrallet
- Department of Internal Medicine and Infectious Diseases, CH de Charleville-Mézières, Charleville-Mézières, France
| | - A Debrumetz
- Department of Nephrology and Transplantation, Reims Teaching Hospitals, Reims, France
| | - M Hentzien
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - T Tabary
- Immunology Laboratory, Reims Teaching Hospitals, Reims, France
| | - R Cohen
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France
| | - G Nicolas
- Department of Neurology, Assistance Publique des Hôpitaux de Paris, Raymond-Poincaré Hospital, Garches, France
| | - F Bani-Sadr
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Reims Teaching Hospitals, Reims, France; University of Reims Champagne-Ardenne, EA-4684 / SFR CAP-SANTE, Reims F-51095, France.
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Nakane S, Mukaino A, Higuchi O, Watari M, Maeda Y, Yamakawa M, Nakahara K, Takamatsu K, Matsuo H, Ando Y. Autoimmune autonomic ganglionopathy: an update on diagnosis and treatment. Expert Rev Neurother 2018; 18:953-965. [PMID: 30352532 DOI: 10.1080/14737175.2018.1540304] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Autoimmune autonomic ganglionopathy (AAG) is an acquired immune-mediated disorder that leads to autonomic failure. The disorder is associated with autoantibodies to the ganglionic nicotinic acetylcholine receptor (gAChR). We subsequently reported that AAG is associated with an overrepresentation of psychiatric symptoms, sensory disturbance, autoimmune diseases, and endocrine disorders. Area covered: The aim of this review was to describe AAG and highlight its pivotal pathophysiological aspects, clinical features, laboratory examinations, and therapeutic options. Expert commentary: AAG is a complex neuroimmunological disease, these days considered as an autonomic failure with extra-autonomic manifestations (and various limited forms). Further comprehension of the pathophysiology of this disease is required, especially the mechanisms of the extra-autonomic manifestations should be elucidated. There is the possibility that the co-presence of antibodies that were directed against the other subunits in both the central and peripheral nAChRs in the serum of the AAG patients. Some patients improve with immunotherapies such as IVIg and/or corticosteroid and/or plasma exchange. 123I-MIBG myocardial scintigraphy may be a useful tool to monitor the therapeutic effects of immunotherapies.
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Affiliation(s)
- Shunya Nakane
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan.,b Department of Molecular Neurology and Therapeutics , Kumamoto University Hospital , Kumamoto , Japan
| | - Akihiro Mukaino
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan.,b Department of Molecular Neurology and Therapeutics , Kumamoto University Hospital , Kumamoto , Japan
| | - Osamu Higuchi
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Mari Watari
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Yasuhiro Maeda
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Makoto Yamakawa
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Keiichi Nakahara
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Koutaro Takamatsu
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
| | - Hidenori Matsuo
- c Department of Neurology and Clinical Research , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Yukio Ando
- a Department of Neurology, Graduate School of Medical Sciences , Kumamoto University , Kumamoto , Japan
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Ketterer B, Montanaro A, Hunter AJ. So Much More than Bald and Bloated. J Hosp Med 2018; 13:863-867. [PMID: 30255858 DOI: 10.12788/jhm.3083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Briana Ketterer
- Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Anthony Montanaro
- Division of Allergy and Immunology, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Alan J Hunter
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Osuagwu FC, Mohiuddin SS, Malas N. Autoimmune Encephalopathy Beyond Anti-NMDAR Encephalitis: The Case of an Adolescent Male with AntiAcetylcholine Receptor Ganglionic Neuronal Antibody Encephalitis. PSYCHOSOMATICS 2018; 60:416-420. [PMID: 30093243 DOI: 10.1016/j.psym.2018.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/09/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Ferdnand C Osuagwu
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Michigan Medical School, MI.
| | - Sarah S Mohiuddin
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Michigan Medical School, MI
| | - Nasuh Malas
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Michigan Medical School, MI; Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, MI
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30
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Lütt A, Michel K, Krüger D, Volz MS, Nassir M, Schulz E, Poralla L, Tangermann P, Bojarski C, Höltje M, Teegen B, Stöcker W, Schemann M, Siegmund B, Prüss H. High prevalence and functional effects of serum antineuronal antibodies in patients with gastrointestinal disorders. Neurogastroenterol Motil 2018; 30:e13292. [PMID: 29345029 DOI: 10.1111/nmo.13292] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 12/20/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Antineuronal antibodies can be associated with both gastrointestinal (GI) and brain disorders. For example, antibodies against the potassium channel subunit dipeptidyl-peptidase-like protein-6 (DPPX) bind to neurons in the central nervous system (CNS) and myenteric plexus and cause encephalitis, commonly preceded by severe unspecific GI symptoms. We therefore investigated the prevalence of antineuronal antibodies indicative of treatable autoimmune CNS etiologies in GI patients. METHODS Serum samples of 107 patients (Crohn's disease n = 42, ulcerative colitis n = 16, irritable bowel syndrome n = 13, others n = 36) and 44 healthy controls were screened for anti-DPPX and further antineuronal antibodies using immunofluorescence on rat brain and intestine and cell-based assays. Functional effects of high-titer reactive sera were assessed in organ bath and Ussing chamber experiments and compared to non-reactive patient sera. KEY RESULTS Twenty-one of 107 patients (19.6%) had antibodies against the enteric nervous system, and 22 (20.6%) had anti-CNS antibodies, thus significantly exceeding frequencies in healthy controls (4.5% each). Screening on cell-based assays excluded established antienteric antibodies. Antibody-positive sera were not associated with motility effects in organ bath experiments. However, they induced significant, tetrodotoxin (TTX)-insensitive secretion in Ussing chambers compared to antibody-negative sera. CONCLUSIONS & INFERENCES Antineuronal antibodies were significantly more frequent in GI patients and associated with functional effects on bowel secretion. Future studies will determine whether such antibodies indicate patients who might benefit from additional antibody-directed therapies. However, well-characterized encephalitis-related autoantibodies such as against DPPX were not detected, underlining their rarity in routine cohorts.
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Affiliation(s)
- A Lütt
- German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - K Michel
- Human Biology, Technical University of Munich, Freising, Germany
| | - D Krüger
- Human Biology, Technical University of Munich, Freising, Germany
| | - M S Volz
- Medical Department (Gastroenterology, Infectious Diseases and Rheumatology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - M Nassir
- Medical Department (Gastroenterology, Infectious Diseases and Rheumatology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - E Schulz
- Medical Department (Gastroenterology, Infectious Diseases and Rheumatology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - L Poralla
- Medical Department (Gastroenterology, Infectious Diseases and Rheumatology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - P Tangermann
- Medical Department (Gastroenterology, Infectious Diseases and Rheumatology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - C Bojarski
- Medical Department (Gastroenterology, Infectious Diseases and Rheumatology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - M Höltje
- Institute for Integrative Neuroanatomy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - B Teegen
- Institute for Experimental Immunology affiliated with Euroimmun, Lübeck, Germany
| | - W Stöcker
- Institute for Experimental Immunology affiliated with Euroimmun, Lübeck, Germany
| | - M Schemann
- Human Biology, Technical University of Munich, Freising, Germany
| | - B Siegmund
- Medical Department (Gastroenterology, Infectious Diseases and Rheumatology), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - H Prüss
- German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Costanzi S, Machado JH, Mitchell M. Nerve Agents: What They Are, How They Work, How to Counter Them. ACS Chem Neurosci 2018; 9:873-885. [PMID: 29664277 DOI: 10.1021/acschemneuro.8b00148] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Nerve agents are organophosphorus chemical warfare agents that exert their action through the irreversible inhibition of acetylcholinesterase, with a consequent overstimulation of cholinergic transmission followed by its shutdown. Beyond warfare, they have notoriously been employed in acts of terrorism as well as high profile assassinations. After a brief historical introduction on the development and deployment of nerve agents, this review provides a survey of their chemistry, the way they affect cholinergic transmission, the available treatment options, and the current directions for their improvement. As the review illustrates, despite their merits, the currently available treatment options present several shortcomings. Current research directions involve the search for improved antidotes, antagonists of the nicotinic receptors, small-molecule pretreatment options, as well as bioscavengers as macromolecular pretreatment options. These efforts are making good progress in many different directions and, hopefully, will lead to a lower target susceptibility, thus reducing the appeal of nerve agents as chemical weapons.
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Affiliation(s)
| | - John-Hanson Machado
- Department of Chemistry, The George Washington University, 800 22nd Street NW, Washington, DC 20052, United States
- Computational Biology Institute, The George Washington University, 45085 University Drive Suite 305, Ashburn, Virginia 20147, United States
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32
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Ashat M, Lewis A, Liaquat H, Stocker A, McElmurray L, Vedanarayanan V, Soota K, Howell T, Kedar A, Obert J, Abell TL. Intravenous immunoglobulin in drug and device refractory patients with the symptoms of gastroparesis-an open-label study. Neurogastroenterol Motil 2018; 30. [PMID: 29205691 DOI: 10.1111/nmo.13256] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 10/29/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastroparesis is a complex clinical entity; many aspects of which remain unknown. Although most patients have idiopathic, diabetic, or postsurgical gastroparesis, many are thought to have measurable neuromuscular abnormalities. Immunotherapy has recently been utilized to treat suspected autoimmune gastrointestinal dysmotility. METHODS Fourteen patients with symptoms of gastroparesis (Gp) who were refractory to drug/device were selected from 443 Gp patients from 2013 to 2015 who were treated at the University of Louisville motility center. All patients underwent a structural and psychiatric evaluation along with detailed psychological and behavioral examination to rule out eating disorders. We performed detailed neuromuscular evaluation and all 14 patients received at least 12 weeks of intravenous immunoglobulin (400 mg/kg infusion weekly). Response was defined subjectively (symptomatic improvement) using standardized IDIOM score system. KEY RESULTS All 14 patients had serological evidence and/or tissue evidence of immunological abnormality. Post-IVIG therapy, there was a significant improvement in symptoms scores for nausea, vomiting, early satiety, and abdominal pain. CONCLUSIONS AND INFERENCES Although limited by the absence of placebo group, the data illustrate the role of autoimmunity and neuromuscular evaluation in patients with gastroparesis and support the utility of a diagnostic trial of immunotherapy in an effort to improve therapeutic outcomes for such patients.
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Affiliation(s)
- M Ashat
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - A Lewis
- Department of Internal Medicine, University of Louisville, Louisville, KY, USA
| | - H Liaquat
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - A Stocker
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - L McElmurray
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - V Vedanarayanan
- Division of Neuromuscular Medicine, University of Mississippi, Oxford, MS, USA
| | - K Soota
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - T Howell
- GI Motility Clinic, Jewish Hospital, Louisville, KY, USA
| | - A Kedar
- Division of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - J Obert
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - T L Abell
- Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, Jewish Hospital GI Motility Clinic, University of Louisville, Louisville, KY, USA
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Long-term cardiovascular autonomic and clinical changes after immunoglobulin G immunoadsorption therapy in autoimmune autonomic ganglionopathy. J Hypertens 2018; 35:1513-1520. [PMID: 28319594 DOI: 10.1097/hjh.0000000000001355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
: A 63-year-old male was diagnosed with autoimmune autonomic ganglionopathy based on the finding of plasma antibodies to the nicotinic acetylcholine receptor (nAChR) of autonomic ganglia. He complained of mouth and eye dryness, dysphagia, severe constipation, erectile dysfunction, urgency, frequent urination, habitual orthostatic syncope and presyncope. A remarkable symptomatic orthostatic hypotension without changes in heart rate was present. We here describe the 3-year time course of the changes in spectral indices of cardiovascular autonomic control LF/HF and LFSAP, dysautonomia symptoms intensity and anti-nAChR antibodies following repetitive selective immunoadsorptions. During the follow-up, the reduction of anti-nAChR antibodies produced by immunoadsorption was associated with a diminished orthostatic hypotension, a restored capability to increase LF/HF, LFSAP and norepinephrine in upright position, a decline in the intensity of autonomic symptoms and an improvement of life quality. Spectral parameters LF/HF and LFSAP may represent noninvasive, low-cost biomarkers suitable for autoimmune autonomic ganglionopathy patients' clinical follow-up.
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Hara M, Yamada S, Nakamura Y, Oka H, Kamimura T, Nakane S, Tsuruya K, Harada A. Autoimmune autonomic ganglionopathy manifesting as acute-onset orthostatic hypotension in a patient undergoing peritoneal dialysis. CEN Case Rep 2017; 5:5-10. [PMID: 28509159 DOI: 10.1007/s13730-015-0180-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 04/02/2015] [Indexed: 11/29/2022] Open
Abstract
Orthostatic hypotension is an important complication in the management of patients receiving dialysis therapy. As for the orthostatic hypotension caused by decreased peripheral artery resistance, diabetic neuropathy and amyloidosis are the two main causes of hypotension in dialysis patients. However, some patients develop orthostatic hypotension that is caused by dysfunction of the autonomic nervous system, not by diabetic or amyloidosis-related neuropathy. We herein present a case of a 56-year-old man with a 17-year history of peritoneal dialysis therapy, who developed acute-onset orthostatic hypotension accompanied by hypohidrosis and erectile dysfunction. Because serum autoantibodies to ganglionic nicotinic acetylcholine receptor were detected, he was diagnosed with autoimmune autonomic ganglionopathy (AAG). He was treated with high-dose immunoglobulin therapy (0.6 g per kg of body weight per day) for 5 consecutive days, which resulted in a gradual improvement in dizziness. Two months after the onset of AAG, he could discontinue vasopressors (fludrocortisone acetate and midodrine hydrochloride) and continued maintenance dialysis therapy without the use of vasopressors. This case indicates that physicians should consider autonomic neuropathy including AAG as a differential diagnosis when they encounter dialysis patients with orthostatic hypotension.
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Affiliation(s)
- Masatoshi Hara
- Division of Nephrology, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Shunsuke Yamada
- Division of Internal Medicine, Fukuoka Dental College, Fukuoka, Japan
| | - Yuuri Nakamura
- Division of Neurology, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Hideaki Oka
- Division of Nephrology, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Taro Kamimura
- Division of Nephrology, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Shunya Nakane
- Department of Clinical Research, Nagasaki Kawatana Medical Center, Kawatana, Nagasaki, Japan
| | - Kazuhiko Tsuruya
- Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Atsumi Harada
- Division of Nephrology, Matsuyama Red Cross Hospital, Matsuyama, Japan
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35
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Kato K, Namiki T, Yokozeki H. Acquired anhidrosis in a case of autoimmune autonomic ganglionopathy. J Dermatol 2016; 44:e36-e37. [DOI: 10.1111/1346-8138.13655] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kohei Kato
- Department of Dermatology; Graduate School of Medical and Dental Sciences; Tokyo Medical and Dental University; Tokyo Japan
| | - Takeshi Namiki
- Department of Dermatology; Graduate School of Medical and Dental Sciences; Tokyo Medical and Dental University; Tokyo Japan
| | - Hiroo Yokozeki
- Department of Dermatology; Graduate School of Medical and Dental Sciences; Tokyo Medical and Dental University; Tokyo Japan
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36
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Wehrwein EA, Orer HS, Barman SM. Overview of the Anatomy, Physiology, and Pharmacology of the Autonomic Nervous System. Compr Physiol 2016; 6:1239-78. [PMID: 27347892 DOI: 10.1002/cphy.c150037] [Citation(s) in RCA: 210] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Comprised of the sympathetic nervous system, parasympathetic nervous system, and enteric nervous system, the autonomic nervous system (ANS) provides the neural control of all parts of the body except for skeletal muscles. The ANS has the major responsibility to ensure that the physiological integrity of cells, tissues, and organs throughout the entire body is maintained (homeostasis) in the face of perturbations exerted by both the external and internal environments. Many commonly prescribed drugs, over-the-counter drugs, toxins, and toxicants function by altering transmission within the ANS. Autonomic dysfunction is a signature of many neurological diseases or disorders. Despite the physiological relevance of the ANS, most neuroscience textbooks offer very limited coverage of this portion of the nervous system. This review article provides both historical and current information about the anatomy, physiology, and pharmacology of the sympathetic and parasympathetic divisions of the ANS. The ultimate aim is for this article to be a valuable resource for those interested in learning the basics of these two components of the ANS and to appreciate its importance in both health and disease. Other resources should be consulted for a thorough understanding of the third division of the ANS, the enteric nervous system. © 2016 American Physiological Society. Compr Physiol 6:1239-1278, 2016.
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Affiliation(s)
- Erica A Wehrwein
- Department of Physiology, Michigan State University, East Lansing, Michigan, USA
| | - Hakan S Orer
- Department of Pharmacology, Koc University School of Medicine, Istanbul, Turkey
| | - Susan M Barman
- Department of Pharmacology &Toxicology, Michigan State University, East Lansing, Michigan, USA
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Mukaino A, Nakane S, Higuchi O, Nakamura H, Miyagi T, Shiroma K, Tokashiki T, Fuseya Y, Ochi K, Umeda M, Nakazato T, Akioka S, Maruoka H, Hayashi M, Igarashi SI, Yokoi K, Maeda Y, Sakai W, Matsuo H, Kawakami A. Insights from the ganglionic acetylcholine receptor autoantibodies in patients with Sjögren's syndrome. Mod Rheumatol 2016; 26:708-15. [PMID: 26873295 DOI: 10.3109/14397595.2016.1147404] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE It is not known whether autonomic neuropathy is a feature of Sjögren's syndrome (SS) or whether it is related to circulating antiganglionic acetylcholine receptor (gAChR) antibodies. The goal of the present study was to investigate the autonomic dysfunction in patients with SS and the associations between autonomic dysfunction, anti-gAChR antibodies, and clinical features of SS. METHODS (1) The first observational study tested for the presence of gAChR antibodies in the serum samples from 39 patients with SS (absent information regarding autonomic symptoms) and healthy volunteers. (2) In the second study, serological and clinical data from 10 Japanese patients diagnosed with SS were reviewed. These patients showed autonomic dysfunction, and luciferase immunoprecipitation systems (LIPS) test was conducted to detect anti-α3 and anti-β4 gAChR antibodies. (3) In the final analysis, we combined the data of seropositive SS patients with autonomic symptom from the first study with all of the patients from the second study, and analyzed the clinical features. RESULTS (1) The LIPS assay revealed that anti-gAChRα3 and anti-gAChRβ4 antibodies were detected in the sera from patients with SS (23.1%, 9/39). Five of nine SS patients had autonomic symptoms. (2) Anti-α3 and anti-β4 gAChR antibodies were also detected in 80.0% (8/10) of patients with SS with autonomic symptoms. Six of the ten patients were diagnosed as having SS after neurological symptoms developed. These seropositive patients had predominant and severe autonomic symptoms and were diagnosed with autonomic neuropathy. (3) Thirteen of fifteen SS patients with autonomic symptoms (86.7%) were seropositive for anti-gAChR antibodies, and we confirmed sicca complex, orthostatic hypotension, upper and lower gastrointestinal (GI) symptoms, and bladder dysfunction at high rates. CONCLUSION The present results suggest the possibility of anti-gAChR antibodies aiding the diagnostics of SS with autonomic dysfunction.
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Affiliation(s)
- Akihiro Mukaino
- a Department of Clinical Neuroscience and Neurology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Shunya Nakane
- b Department of Clinical Research and.,c Department of Neurology , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | | | - Hideki Nakamura
- d Department of Immunology and Rheumatology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Tomo Miyagi
- e Department of Cardiovascular Medicine, Nephrology and Neurology , University of the Ryukyu School of Medicine , Okinawa , Japan
| | - Kanako Shiroma
- e Department of Cardiovascular Medicine, Nephrology and Neurology , University of the Ryukyu School of Medicine , Okinawa , Japan
| | - Takashi Tokashiki
- e Department of Cardiovascular Medicine, Nephrology and Neurology , University of the Ryukyu School of Medicine , Okinawa , Japan
| | - Yasuhiro Fuseya
- f Department of Neurology , Kitano Hospital Medical Research Institute , Osaka , Japan
| | - Kazuhide Ochi
- g Department of Neurology , Hiroshima University Hospital , Hiroshima , Japan
| | - Masataka Umeda
- d Department of Immunology and Rheumatology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Tetsuya Nakazato
- h Department of Neurology , Sapporo Yamanoue Hospital , Sapporo , Japan
| | - Shinji Akioka
- i Department of Pediatrics, Graduate School of Medical Science , Kyoto Prefectural University of Medicine , Kyoto , Japan
| | - Hiroyuki Maruoka
- j Department of Neurology and Neurological Science, and Predictive and Preventive Medicine , Tokyo Medical and Dental University , Tokyo , Japan
| | | | - Shu-Ichi Igarashi
- l Department of Neurology , Niigata City General Hospital , Niigata , Japan , and
| | - Katsunori Yokoi
- m Department of Neurology , Anjo Kosei Hospital , Aichi , Japan
| | - Yasuhiro Maeda
- c Department of Neurology , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Waka Sakai
- c Department of Neurology , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Hidenori Matsuo
- c Department of Neurology , Nagasaki Kawatana Medical Center , Nagasaki , Japan
| | - Atsushi Kawakami
- d Department of Immunology and Rheumatology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
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Ganglionic acetylcholine receptor autoantibodies in patients with Guillain-Barré syndrome. J Neuroimmunol 2016; 295-296:54-9. [PMID: 27235349 DOI: 10.1016/j.jneuroim.2016.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 04/13/2016] [Accepted: 04/16/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Although standardized autonomic tests are useful for diagnosing autonomic failure in patients with Guillain-Barré syndrome (GBS), they cannot be used as predictive markers. Thus, serological markers may correctly identify patients with GBS who are at risk for autonomic dysfunction. METHODS We validated a luciferase immunoprecipitation system that detects IgG antibodies in patient serum that specifically bind to the α3 or β4 subunits of ganglionic neuronal nicotinic acetylcholine receptors (gAChR). We then used luciferase-conjugated ligands specific to antibodies against two gAChR subunits to test 79 sera samples from patients with GBS, 34 from subjects with other neurological diseases (OND), and 73 from healthy controls (HC). 1) In the first analysis, patients were classified into two groups according to the presence or absence of autonomic symptoms (AS). We compared the frequency of the anti-gAChR antibodies between these two groups (AS+ and AS-). 2) In the second analysis, furthermore, patients were classified depending on the presence or absence of anti-glycolipid antibodies (AGA). We compared the frequency of the anti-gAChR antibodies between the four categories of GBS (AS+/AGA+, AS+/AGA-, AS-/AGA+, and AS-/AGA-), OND, and HC. RESULTS Eight subjects with GBS were positive for α3 subunits, while one was positive for β4 subunits. Anti-α3 and -β4 gAChR antibodies were also detected in 13.6% of AS+ GBS group in the first analysis. Two of 35 patients in AS-GBS group were seropositive for the anti-gAChR antibodies and AGA in the second analysis. Patients with GBS that were positive for serum antibodies to the α3 and/or β4 subunits of gAChRs showed a range of clinical features including AS and AGA. CONCLUSIONS Patients with GBS may have circulating antibodies against gAChR, which may contribute to the autonomic dysfunction associated with this disease.
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Cheshire WP. Thermoregulatory disorders and illness related to heat and cold stress. Auton Neurosci 2016; 196:91-104. [DOI: 10.1016/j.autneu.2016.01.001] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/17/2015] [Accepted: 01/05/2016] [Indexed: 01/22/2023]
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Generalized pan-autonomic failure as a presenting sign of Bickerstaff’s brainstem encephalitis. Neurol Sci 2016; 37:1001-3. [DOI: 10.1007/s10072-016-2478-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 01/09/2016] [Indexed: 10/22/2022]
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Abstract
Autoimmune autonomic disorders occur because of an immune response directed against sympathetic, parasympathetic, and enteric ganglia, autonomic nerves, or central autonomic pathways. In general, peripheral autoimmune disorders manifest with either generalized or restricted autonomic failure, whereas central autoimmune disorders manifest primarily with autonomic hyperactivity. Some autonomic disorders are generalized, and others are limited in their anatomic extent, e.g., isolated gastrointestinal dysmotility. Historically, these disorders were poorly recognized, and thought to be neurodegenerative. Over the last 20 years a number of autoantibody biomarkers have been discovered that have enabled the identification of certain patients as having an autoimmune basis for either autonomic failure or hyperactivity. Peripheral autoimmune autonomic disorders include autoimmune autonomic ganglionopathy (AAG), paraneoplastic autonomic neuropathy, and acute autonomic and sensory neuropathy. AAG manifests with acute or subacute onset of generalized or selective autonomic failure. Antibody targeting the α3 subunit of the ganglionic-type nicotinic acetylcholine receptor (α3gAChR) is detected in approximately 50% of cases of AAG. Some other disorders are characterized immunologically by paraneoplastic antibodies with a high positive predictive value for cancer, such as antineuronal nuclear antibody, type 1 (ANNA-1: anti-Hu); others still are seronegative. Recognition of an autoimmune basis for autonomic disorders is important, as their manifestations are disabling, may reflect an underlying neoplasm, and have the potential to improve with a combination of symptomatic and immune therapies.
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Affiliation(s)
- Andrew Mckeon
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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Kim HG, Cho SM, Lee CK, Jeong SW. Neuregulin 1 as an endogenous regulator of nicotinic acetylcholine receptors in adult major pelvic ganglion neurons. Biochem Biophys Res Commun 2015; 463:632-7. [DOI: 10.1016/j.bbrc.2015.05.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 05/29/2015] [Indexed: 10/23/2022]
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Hendrickson JE, Hendrickson ET, Gehrie EA, Sidhu D, Wallukat G, Schimke I, Tormey CA. Complex regional pain syndrome and dysautonomia in a 14-year-old girl responsive to therapeutic plasma exchange. J Clin Apher 2015; 31:368-74. [DOI: 10.1002/jca.21407] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 05/01/2015] [Indexed: 01/19/2023]
Affiliation(s)
- Jeanne E. Hendrickson
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven Connecticut
- Department of Pediatrics; Yale University School of Medicine; New Haven Connecticut
| | | | - Eric A. Gehrie
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven Connecticut
| | - Davinder Sidhu
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven Connecticut
| | - Gerd Wallukat
- Berlin Cures GmbH; Berlin Germany
- Max Delbrück Center for Moleculare Medicine; Berlin Germany
| | | | - Christopher A. Tormey
- Department of Laboratory Medicine; Yale University School of Medicine; New Haven Connecticut
- VA Connecticut Healthcare System; West Haven Connecticut
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Nakane S, Higuchi O, Koga M, Kanda T, Murata K, Suzuki T, Kurono H, Kunimoto M, Kaida KI, Mukaino A, Sakai W, Maeda Y, Matsuo H. Clinical features of autoimmune autonomic ganglionopathy and the detection of subunit-specific autoantibodies to the ganglionic acetylcholine receptor in Japanese patients. PLoS One 2015; 10:e0118312. [PMID: 25790156 PMCID: PMC4366081 DOI: 10.1371/journal.pone.0118312] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 01/14/2015] [Indexed: 01/08/2023] Open
Abstract
Autoimmune autonomic ganglionopathy (AAG) is a rare acquired channelopathy that is characterized by pandysautonomia, in which autoantibodies to ganglionic nicotinic acetylcholine receptors (gAChR) may play a central role. Radioimmunoprecipitation (RIP) assays have been used for the sensitive detection of autoantibodies to gAChR in the serum of patients with AAG. Here, we developed luciferase immunoprecipitation systems (LIPS) to diagnose AAG based on IgGs to both the α3 and β4 gAChR subunits in patient serum. We reviewed the serological and clinical data of 50 Japanese patients who were diagnosed with AAG. With the LIPS testing, we detected anti-α3 and -β4 gAChR antibodies in 48% (24/50) of the patients. A gradual mode of onset was more common in the seropositive group than in the seronegative group. Patients with AAG frequently have orthostatic hypotension and upper and lower gastrointestinal tract symptoms, with or without anti-gAChR. The occurrence of autonomic symptoms was not significantly different between the seropositive and seronegative group, with the exception of achalasia in three patients from the seropositive group. In addition, we found a significant overrepresentation of autoimmune diseases in the seropositive group and endocrinological abnormalities as an occasional complication of AAG. Our results demonstrated that the LIPS assay was a useful novel tool for detecting autoantibodies against gAChR in patients with AAG.
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Affiliation(s)
- Shunya Nakane
- Department of Clinical Research, Nagasaki Kawatana Medical Center, Nagasaki, Japan; Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Osamu Higuchi
- Department of Clinical Research, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Kenya Murata
- Department of Neurology, Wakayama Medical University, Wakayama, Japan
| | - Takashi Suzuki
- Department of Neurology, Joetsu General Hospital, Niigata, Japan
| | - Hiroko Kurono
- Department of Neurology, Saiseikai Kanagawa Prefecture Hospital, Kanagawa, Japan
| | - Masanari Kunimoto
- Department of Neurology, Saiseikai Kanagawa Prefecture Hospital, Kanagawa, Japan
| | - Ken-ichi Kaida
- Division of Neurology, Department of Internal Medicine 3, National Defense Medical College, Saitama, Japan
| | - Akihiro Mukaino
- Department of Clinical Neuroscience and Neurology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Waka Sakai
- Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Yasuhiro Maeda
- Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Hidenori Matsuo
- Department of Neurology, Nagasaki Kawatana Medical Center, Nagasaki, Japan
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Li J, Zhang Q, Liao Y, Zhang C, Hao H, Du J. The value of acetylcholine receptor antibody in children with postural tachycardia syndrome. Pediatr Cardiol 2015; 36:165-70. [PMID: 25087056 DOI: 10.1007/s00246-014-0981-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 07/22/2014] [Indexed: 01/06/2023]
Abstract
Postural tachycardia syndrome (POTS) is characterized by symptoms of orthostatic intolerance. Antibodies of acetylcholine receptor (AChR-ab) affect acetylcholine transmission between the ganglia and result in imbalance of the autonomic nervous system in POTS. This study was designed to analyze the clinical characteristics of POTS patients with AChR-ab positive and explore the value of AChR-ab in children with POTS. In 82 children with POTS, twenty patients (24.39%) were found as AChR-ab positive. Their clinical characteristics and hemodynamic responses to orthostatic changes were compared with the remaining 60 patients with negative AChR-ab. Symptoms of POTS children with AChR-ab positive were significantly severe than those of AChR-ab negative patients (p = 0.001). Preceding infection was predominant in patients with AChR-ab positive compared with that of patients with AChR-ab negative (p < 0.001). Syncope and fatigue were more common in the AChR-ab positive patients (p < 0.05). The change of upright heart rate was increased significantly in AChR-ab positive patients compared with AChR-ab negative cases (p = 0.013). Multiple logistic regression analysis revealed that preceding infection (OR 22.356, 95% CI 2.151-34.920), syncope (OR 11.570, 95% CI 2.098-63.810), and fatigue (OR 11.145, 95% CI 1.658-74.911) were independent risk factors for POTS with AChR-ab positive. In conclusion, POTS with positive AChR-ab was a heterogeneous disorder. Preceding infection, syncope and fatigue were their main clinical characteristics.
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Affiliation(s)
- Jiawei Li
- Department of Pediatrics, Peking University First Hospital, Xi-An Men Street No. 1, West District, Beijing, 100034, China
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Baker SK, Chow BM, Vernino SA. Transient neonatal autoimmune autonomic ganglionopathy. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2014; 1:e35. [PMID: 25340087 PMCID: PMC4204229 DOI: 10.1212/nxi.0000000000000035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 08/26/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Steven K Baker
- Department of Medicine (S.K.B., B.M.C.), Divisions of Physical Medicine & Neurology, Neuromuscular Disease Clinic, McMaster University Medical Center, Hamilton, Ontario, Canada; and Department of Neurology & Neurotherapeutics (S.A.V.), University of Texas Southwestern Medical Center, Dallas, TX
| | - Beverly M Chow
- Department of Medicine (S.K.B., B.M.C.), Divisions of Physical Medicine & Neurology, Neuromuscular Disease Clinic, McMaster University Medical Center, Hamilton, Ontario, Canada; and Department of Neurology & Neurotherapeutics (S.A.V.), University of Texas Southwestern Medical Center, Dallas, TX
| | - Steven A Vernino
- Department of Medicine (S.K.B., B.M.C.), Divisions of Physical Medicine & Neurology, Neuromuscular Disease Clinic, McMaster University Medical Center, Hamilton, Ontario, Canada; and Department of Neurology & Neurotherapeutics (S.A.V.), University of Texas Southwestern Medical Center, Dallas, TX
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Hundsberger T, Omlin A, Haegele-Link S, Vehoff J, Strasser F. Autonomic dysfunction in cancer cachexia coincides with large fiber polyneuropathy. J Pain Symptom Manage 2014; 48:611-8.e1. [PMID: 24709363 DOI: 10.1016/j.jpainsymman.2013.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 11/16/2013] [Accepted: 11/21/2013] [Indexed: 01/06/2023]
Abstract
CONTEXT Cancer cachexia occurs in most patients suffering from solid malignancies. Recent works suggest paraneoplastic mechanisms. Empirical studies also found autonomic dysfunction in cancer patients, but comprehensive evaluation of the peripheral nervous system is lacking. OBJECTIVES To further understand the role of the autonomic and peripheral nervous system in cancer cachexia to guide treatment. METHODS We prospectively investigated cachectic cancer patients for parasympathetic autonomic dysfunction with a time-domain-based analysis of heart rate variability (breathing at rest, deep breath, and in response to the Valsalva maneuver). Blood pressure changes after the Valsalva maneuver were used as a marker of the sympathetic noradrenergic system. Orthostatic hypertension was investigated in response to active standing. We used a noninvasive continuous beat-to-beat heart rate assessment and blood pressure monitoring. The sympathetic cholinergic nervous system was evaluated with the sympathetic skin response. A detailed neurological examination, nerve conduction studies, and electromyography also were conducted. RESULTS A total of 13 patients were enrolled (median age 66 years). Median time from inclusion until death was 3.5 months. About 12 of the 13 patients showed abnormal results in at least one autonomic test. Sympathetic noradrenergic and cholinergic abnormalities were discovered in six patients each and five patients had orthostatic hypotension. Only one patient showed abnormal results in parasympathetic cholinergic tests. Asymptomatic large fiber polyneuropathy was detected in eight patients. CONCLUSION Large fiber polyneuropathy coincides with autonomic dysfunction in cachectic cancer patients. Our findings suggest a relevant role of sympathetic impairment in cancer cachexia.
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Affiliation(s)
- Thomas Hundsberger
- Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland; Department of Hematology and Oncology, Cantonal Hospital, St. Gallen, Switzerland.
| | - Aurelius Omlin
- Department of Hematology and Oncology, Cantonal Hospital, St. Gallen, Switzerland
| | | | - Jochen Vehoff
- Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Florian Strasser
- Department of Hematology and Oncology, Cantonal Hospital, St. Gallen, Switzerland
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The presence of dysautonomia in different subgroups of myasthenia gravis patients. J Neurol 2014; 261:2119-27. [DOI: 10.1007/s00415-014-7465-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 08/05/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022]
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Shibao C, Muppa P, Semler MW, Peltier AC, Biaggioni I. A standing dilemma: autonomic failure preceding Hodgkin's lymphoma. Am J Med 2014; 127:284-7. [PMID: 24333616 PMCID: PMC4099002 DOI: 10.1016/j.amjmed.2013.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 12/03/2013] [Accepted: 12/03/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Cyndya Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Autonomic Dysfunction Center, Vanderbilt University Medical Center, Nashville, Tenn
| | - Prasuna Muppa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Amanda C Peltier
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Autonomic Dysfunction Center, Vanderbilt University Medical Center, Nashville, Tenn.
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Abstract
Orthostatic hypotension is a condition commonly affecting the elderly and is often accompanied by disabling presyncopal symptoms, syncope and impaired quality of life. The pathophysiology of orthostatic hypotension is linked to abnormal blood pressure regulatory mechanisms and autonomic insufficiency. As part of its diagnostic evaluation, a comprehensive history and medical examination focused on detecting symptoms and physical findings of autonomic neuropathy should be performed. In individuals with substantial falls in blood pressure upon standing, autonomic function tests are recommended to detect impairment of autonomic reflexes. Treatment should always follow a stepwise approach with initial use of nonpharmacologic interventions including avoidance of hypotensive medications, high-salt diet and physical counter maneuvers. If these measures are not sufficient, medications such as fludrocortisone and midodrine can be added. The goals of treatment are to improve symptoms and to make the patient as ambulatory as possible instead of targeting arbitrary blood pressure values.
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Affiliation(s)
- Amy C Arnold
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN 37232-8802, USA
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