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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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Lenka A, Isonaka R, Holmes C, Goldstein DS. Cardiac 18F-Dopamine Positron Emission Tomography Predicts the Type of Phenoconversion of Pure Autonomic Failure. RESEARCH SQUARE 2023:rs.3.rs-3157807. [PMID: 37503103 PMCID: PMC10371148 DOI: 10.21203/rs.3.rs-3157807/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Background Pure autonomic failure (PAF) is a rare disease characterized clinically by neurogenic orthostatic hypotension (nOH) and biochemically by peripheral noradrenergic deficiency. Clinically diagnosed PAF can evolve ("phenoconvert") to a central Lewy body disease (LBD, e.g., Parkinson's disease (PD) or dementia with Lewy bodies (DLB)) or to the non-LBD synucleinopathy multiple system atrophy (MSA). We examined whether cardiac 18F-dopamine positron emission tomography (PET) predicts the trajectory of phenoconversion in PAF. Since cardiac 18F-dopamine-derived radioactivity always is decreased in LBDs with nOH and usually is normal in MSA, we hypothesized that PAF patients with low cardiac 18F-dopamine-derived radioactivity may phenoconvert to a central LBD but do not phenoconvert to MSA. Methods We reviewed data from all the patients seen at the National Institutes of Health Clinical Center from 1994 to 2023 with a clinical diagnosis of PAF and data about serial 18F-dopamine PET. Results Twenty patients met the above criteria. Of 15 with low cardiac 18F-dopamine-derived radioactivity, 6 (40%) phenoconverted to PD or DLB and none to MSA. Of 5 patients with consistently normal 18F-dopamine PET, 4 phenoconverted to MSA, and the other at autopsy had neither a central LBD nor MSA. Conclusion In this case series, 40% of patients with nOH and low cardiac 18F-dopamine-derived radioactivity phenoconverted to PD or DLB during follow-up; none phenoconverted to MSA. Cardiac 18F-DA PET therefore can predict the type of phenoconversion in PAF. This capability could refine eligibility criteria for entry into disease-modification trials aiming to prevent evolution of PAF to symptomatic central LBDs.
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Affiliation(s)
| | - Risa Isonaka
- National Institute of Neurological Disorders and Stroke Intramural Research Program
| | - Courtney Holmes
- National Institute of Neurological Disorders and Stroke Intramural Research Program
| | - David S Goldstein
- National Institute of Neurological Disorders and Stroke Intramural Research Program
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Pure autonomic failure and the differential diagnosis of autonomic peripheral neuropathies. Curr Opin Neurol 2021; 34:675-682. [PMID: 34392300 DOI: 10.1097/wco.0000000000000985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF THE REVIEW Pure autonomic failure (PAF) is a peripheral autonomic neurodegenerative disease caused by alpha-synuclein deposition that is predominantly confined to peripheral autonomic neurons. Patients present with insidious features of autonomic failure that have a chronic course.In this review, we highlight the features of PAF, the differentiating features from other autonomic neuropathies, the diagnostic tests, and the predictors for conversion to a central synucleinopathy. RECENT FINDINGS Natural history studies have defined the predictors for and rate of conversion to a central alpha-synucleinopathy. Skin immunohistochemistry techniques and demonstration of length-dependent neuronal loss of both somatic and autonomic small fiber nerves, and intraneural phosphorylated synuclein deposition provide diagnostic biomarkers. In the future, diagnosis maybe supported by measuring cerebrospinal fluid alpha-synuclein oligomers using techniques, such as protein misfolding cyclic amplification assay and real-time quaking-induced conversion. SUMMARY PAF is a sporadic peripheral autonomic neurodegenerative disease that belongs to the group of disorders known as alpha-synucleinopathies. Peripheral autonomic manifestations are similar to those seen in other autonomic neuropathies, particularly, diabetic autonomic neuropathy, amyloid polyneuropathy, and autoimmune autonomic neuropathies. Novel diagnostic procedures like skin immunohistochemistry for alpha-synuclein, and protein amplification techniques are being investigated to provide an earlier and more specific diagnosis. A substantial number of PAF patients' phenoconvert to a central alpha-synucleinopathy.
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Williams ML. Global warming, heat-related illnesses, and the dermatologist. Int J Womens Dermatol 2020; 7:70-84. [PMID: 33537396 PMCID: PMC7838243 DOI: 10.1016/j.ijwd.2020.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 12/23/2022] Open
Abstract
Global warming, provoked by the greenhouse effect of high levels of atmospheric gases (most notably carbon dioxide and methane), directly threatens human health and survival. Individuals vary in their capacity to tolerate episodes of extreme heat. Because skin is the organ tasked with heat dissipation, it is important for dermatologists to be versed in the physiology of cutaneous heat dissipation and cognizant of clinical settings in which the skin’s thermoregulatory responses may be impaired. When the external temperature is lower than that of the skin, the skin releases internal heat through direct thermal exchange with the environment, a process that is aided by an expansion of cutaneous blood flow and eccrine sweating. Cooling through the evaporation of sweat is effective even when the external temperature exceeds that of skin. Many factors, including environmental and physiological (e.g., age and sex), and pathological (e.g., preexisting illnesses, disorders of eccrine function, and medications) considerations, affect the skin’s capacity to thermoregulate. Identification of individuals at increased risk for heat-related morbidity and mortality will become increasingly important in the care of patients.
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Affiliation(s)
- Mary L Williams
- Departments of Dermatology and Pediatrics, University of California San Francisco, San Francisco, CA, United States
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Abstract
Autonomic dysfunction is a characteristic feature in the synucleinopathies. Differences in cellular deposition and neuronal populations affected by α-synuclein aggregation influence the manifestations and severity of autonomic failure in the different synucleinopathy disorders. The Lewy body disorders (Parkinson's disease, dementia with Lewy bodies, and pure autonomic failure) have predominantly peripheral involvement, whereas multiple system atrophy chiefly manifests as central autonomic failure. Clinical and laboratory features may be useful in distinguishing the different synucleinopathies based on the pattern and severity of autonomic failure. Treatment recommendations are aimed at the underlying pathophysiology and utilize non-pharmacologic and pharmacologic approaches. This review will focus on pathophysiology, clinical manifestations, and management recommendations for autonomic failure including neurogenic orthostatic hypotension, thermoregulatory dysfunction, genitourinary dysfunction, and gastrointestinal dysfunction in the synucleinopathies.
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Nakane S, Mukaino A, Higuchi O, Yasuhiro M, Takamatsu K, Yamakawa M, Watari M, Tawara N, Nakahara KI, Kawakami A, Matsuo H, Ando Y. A comprehensive analysis of the clinical characteristics and laboratory features in 179 patients with autoimmune autonomic ganglionopathy. J Autoimmun 2020; 108:102403. [PMID: 31924415 DOI: 10.1016/j.jaut.2020.102403] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/29/2019] [Accepted: 01/01/2020] [Indexed: 12/12/2022]
Abstract
The clinical importance of autoantibodies against the ganglionic acetylcholine receptor (gAChR) remains to be fully elucidated. We aimed to identify the clinical characteristics of autoimmune autonomic ganglionopathy (AAG) in patients with gAChR autoantibodies. For this cohort investigation, serum samples were obtained from patients with AAG between 2012 and 2018 in Japan. We measured the levels of autoantibodies against gAChRα3 and gAChRβ4 and evaluated clinical features, as well as assessing the laboratory investigation results among the included patients. A total of 179 patients tested positive for antibodies, including 116 gAChRα3-positive, 13 gAChRβ4-positive, and 50 double antibody-positive patients. Seropositive AAG patients exhibited widespread autonomic dysfunction. Extra-autonomic manifestations including sensory disturbance, central nervous system involvement, endocrine disorders, autoimmune diseases, and tumours were present in 118 patients (83%). We observed significant differences in the frequencies of several autonomic and extra-autonomic symptoms among the three groups. Our 123I-metaiodobenzylguanidine myocardial scintigraphy analysis of the entire cohort revealed that the heart-to-mediastinum ratio had decreased by 80%. The present study is the first to demonstrate that patients with AAG who are seropositive for anti-gAChRβ4 autoantibodies exhibit unique autonomic and extra-autonomic signs. Decreased cardiac uptake occurred in most cases, indicating that 123I- metaiodobenzylguanidine myocardial scintigraphy may be useful for monitoring AAG. Therefore, our findings indicate that gAChRα3 and gAChRβ4 autoantibodies cause functional changes in postganglionic fibres in the autonomic nervous system and extra-autonomic manifestations in seropositive patients with AAG.
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Affiliation(s)
- Shunya Nakane
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan.
| | - Akihiro Mukaino
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Molecular Neurology and Therapeutics, Kumamoto University Hospital, Kumamoto, Japan.
| | - Osamu Higuchi
- Department of Clinical Research, National Hospital Organization Nagasaki Kawatana Medical Center, Nagasaki, Japan; Department of Neuroimmunology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
| | - Maeda Yasuhiro
- Department of Clinical Research, National Hospital Organization Nagasaki Kawatana Medical Center, Nagasaki, Japan; Department of Neuroimmunology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; 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.
| | - Makoto Yamakawa
- 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.
| | - Nozomu Tawara
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Kei-Ichi Nakahara
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Unit of Translational Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan.
| | - Hidenori Matsuo
- Department of Clinical Research, National Hospital Organization Nagasaki Kawatana Medical Center, Nagasaki, Japan; 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.
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Coon EA, Singer W, Low PA. Pure Autonomic Failure. Mayo Clin Proc 2019; 94:2087-2098. [PMID: 31515103 PMCID: PMC6826339 DOI: 10.1016/j.mayocp.2019.03.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 03/06/2019] [Accepted: 03/12/2019] [Indexed: 12/17/2022]
Abstract
Pure autonomic failure (PAF) is a neurodegenerative disorder of the autonomic nervous system clinically characterized by orthostatic hypotension. The disorder has also been known as Bradbury-Eggleston syndrome, named for the authors of the 1925 seminal description. Patients typically present in midlife or later with orthostatic hypotension or syncope. Autonomic failure may also manifest as genitourinary, bowel, and thermoregulatory dysfunction. With widespread involvement, patients may present to a variety of different specialties and require multidisciplinary treatment approaches. Pathologically, PAF is characterized by predominantly peripheral deposition of α-synuclein. However, patients with PAF may progress into other synucleinopathies with central nervous system involvement.
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Isonaka R, Rosenberg AZ, Sullivan P, Corrales A, Holmes C, Sharabi Y, Goldstein DS. Alpha-Synuclein Deposition Within Sympathetic Noradrenergic Neurons Is Associated With Myocardial Noradrenergic Deficiency in Neurogenic Orthostatic Hypotension. Hypertension 2019; 73:910-918. [PMID: 30798661 PMCID: PMC6472912 DOI: 10.1161/hypertensionaha.118.12642] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Lewy body diseases involve neurogenic orthostatic hypotension (nOH), cardiac noradrenergic deficiency, and deposition of the protein AS (alpha-synuclein) in sympathetic ganglion tissue. Mechanisms linking these abnormalities are poorly understood. One link may be AS deposition within sympathetic neurons. We validated methodology to quantify AS colocalization with TH (tyrosine hydroxylase), a marker of sympathetic noradrenergic innervation, and assessed associations of AS/TH colocalization with myocardial norepinephrine content and cardiac sympathetic neuroimaging data in nOH. Postmortem sympathetic ganglionic AS/TH colocalization indices and myocardial norepinephrine contents were measured in 4 Lewy body and 3 rare non-Lewy body nOH patients. Sixteen Lewy body and 11 non-Lewy body nOH patients underwent in vivo skin biopsies and thoracic 18F-dopamine positron emission tomographic scanning, with cutaneous colocalization indices expressed versus cardiac 18F-dopamine-derived radioactivity. Ganglionic AS/TH colocalization indices were higher and myocardial norepinephrine lower in Lewy body than non-Lewy body nOH ( P=0.0020, P=0.014). The Lewy body nOH group had higher AS/TH colocalization indices in skin biopsies and lower myocardial 18F-dopamine-derived radioactivity than did the non-Lewy body nOH group ( P<0.0001 each). All Lewy body nOH patients had colocalization indices >1.5 in skin biopsies and 18F-dopamine-derived radioactivity <6000 nCi-kg/cc-mCi, a combination not seen in non-Lewy body nOH patients ( P<0.0001). In Lewy body nOH, AS deposition in sympathetic noradrenergic nerves is related to postmortem neurochemical and in vivo neuroimaging evidence of myocardial noradrenergic deficiency. These associations raise the possibility that intraneuronal AS deposition plays a pathophysiological role in the myocardial sympathetic neurodegeneration attending Lewy body nOH.
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Affiliation(s)
- Risa Isonaka
- Autonomic Medicine Section (formerly Clinical Neurocardiology Section), Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Avi Z. Rosenberg
- Department of Pathology Johns Hopkins School of Medicine, Baltimore, MD
| | - Patti Sullivan
- Autonomic Medicine Section (formerly Clinical Neurocardiology Section), Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Abraham Corrales
- Autonomic Medicine Section (formerly Clinical Neurocardiology Section), Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Courtney Holmes
- Autonomic Medicine Section (formerly Clinical Neurocardiology Section), Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | | | - David S. Goldstein
- Autonomic Medicine Section (formerly Clinical Neurocardiology Section), Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
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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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Goldstein DS, Cheshire WP. Roles of catechol neurochemistry in autonomic function testing. Clin Auton Res 2018; 28:273-288. [PMID: 29705971 DOI: 10.1007/s10286-018-0528-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/10/2018] [Indexed: 12/14/2022]
Abstract
Catechols are a class of compounds that contain adjacent hydroxyl groups on a benzene ring. Endogenous catechols in human plasma include the catecholamines norepinephrine, epinephrine (adrenaline), and dopamine; the catecholamine precursor DOPA, 3,4-dihydroxyphenylglycol (DHPG), which is the main neuronal metabolite of norepinephrine; and 3,4-dihydroxyphenylacetic acid (DOPAC), which is the main neuronal metabolite of dopamine. In the diagnostic evaluation of patients with known or suspected dysautonomias, measurement of plasma catechols is rarely diagnostic but often is informative. This review summarizes the roles of clinical catechol neurochemistry in autonomic function testing.
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Affiliation(s)
- David S Goldstein
- Clinical Neurocardiology Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 9000 Rockville Pike MSC-1620, Building 10 Room 8N260, Bethesda, MD, 20892-1620, USA.
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Seronegative and seropositive autoimmune autonomic ganglionopathy (AAG): Same clinical picture, same response to immunotherapy. J Neuroimmunol 2018; 319:68-70. [PMID: 29685292 DOI: 10.1016/j.jneuroim.2018.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 03/24/2018] [Accepted: 03/28/2018] [Indexed: 11/21/2022]
Abstract
Two patients with a syndrome of pandisautonomia with clinical criteria of AAG are provided. Both patients present a similar clinical picture and response to immunosuppressive treatment. One of them has positive antibodies against the ganglionic nicotinic acetylcholine (gAChr) and the other does not. This brief article serves to reflect the spectrum of AAG, at a clinical level, in laboratory tests and in the response to immunotherapy, independently of the presence of positive gAChr antibodies.
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Goldstein DS, Holmes C, Sullivan P, Mash DC, Sidransky E, Stefani A, Kopin IJ, Sharabi Y. Deficient vesicular storage: A common theme in catecholaminergic neurodegeneration. Parkinsonism Relat Disord 2015; 21:1013-22. [PMID: 26255205 DOI: 10.1016/j.parkreldis.2015.07.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 07/06/2015] [Accepted: 07/14/2015] [Indexed: 01/13/2023]
Abstract
Several neurodegenerative diseases involve loss of catecholamine neurons--Parkinson's disease (PD) is a prototypical example. Catecholamine neurons are rare in the nervous system, and why they are lost has been mysterious. Accumulating evidence supports the concept of "autotoxicity"--inherent cytotoxicity caused by catecholamine metabolites. Since vesicular sequestration limits the buildup of toxic products of enzymatic and spontaneous oxidation of catecholamines, a vesicular storage defect could play a pathogenic role in the death of catecholaminergic neurons in a variety of neurodegenerative diseases. In putamen, deficient vesicular storage is revealed in vivo by accelerated loss of (18)F-DOPA-derived radioactivity and post-mortem by decreased tissue dopamine (DA):DOPA ratios; in myocardium in vivo by accelerated loss of (18)F-dopamine-derived radioactivity and post-mortem by increased 3,4-dihydroxyphenylglycol:norepinephrine (DHPG:NE) ratios; and in sympathetic noradrenergic nerves overall in vivo by increased plasma F-dihydroxyphenylacetic acid (F-DOPAC):DHPG ratios. We retrospectively analyzed data from 20 conditions with decreased or intact catecholaminergic innervation, involving different etiologies, pathogenetic mechanisms, and lesion locations. All conditions involving parkinsonism had accelerated loss of putamen (18)F-DOPA-derived radioactivity; in those with post-mortem data there were also decreased putamen DA:DOPA ratios. All conditions involving cardiac sympathetic denervation had accelerated loss of myocardial (18)F-dopamine-derived radioactivity; in those with post-mortem data there were increased myocardial DHPG:NE ratios. All conditions involving localized loss of catecholaminergic innervation had evidence of decreased vesicular storage specifically in the denervated regions. Thus, across neurodegenerative diseases, loss of catecholaminergic neurons seems to be associated with decreased vesicular storage in the residual neurons.
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Affiliation(s)
- David S Goldstein
- Clinical Neurocardiology Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Courtney Holmes
- Clinical Neurocardiology Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Patti Sullivan
- Clinical Neurocardiology Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Deborah C Mash
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Ellen Sidransky
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | | | - Irwin J Kopin
- Clinical Neurocardiology Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Yehonatan Sharabi
- Department of Internal Medicine, Chaim Sheba Medical Center, Tel-HaShomer, and Sackler Faculty of Medicine, Tel-Aviv University School of Medicine, Tel-Avid, Israel
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Abstract
We describe a 13-year-old female with abrupt onset urinary retention progressing rapidly to pandysautonomia with symptoms of postural orthostatic tachycardia syndrome, gastroparesis, anhidrosis, pupillary dysfunction, and abdominal pain. Pandysautonomia has been reported frequently in adults, but is less commonly described in children. Autonomic nervous system dysfunction usually has a self-limiting course with gradual near-complete or complete recovery. Most patients with pure pandysautonomia produce an antibody targeted against the ganglionic nicotinic acetylcholine receptor and titers have been shown to correlate with symptom severity. The clinical presentation described in this report is consistent with a progressive form of acute autoimmune autonomic neuropathy, but she was initially seronegative for known autoantibodies. She responded promptly to plasmapheresis. This case report emphasizes the importance of recognizing features of autonomic nervous system dysfunction and discusses the medical evaluation and treatment options for pediatric patients based on symptom severity.
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Koike H, Hashimoto R, Tomita M, Kawagashira Y, Iijima M, Koyano S, Momoo T, Yuasa H, Mitake S, Higashihara M, Kaida K, Yamamoto D, Hisahara S, Shimohama S, Nakae Y, Johkura K, Vernino S, Sobue G. The spectrum of clinicopathological features in pure autonomic neuropathy. J Neurol 2012; 259:2067-75. [PMID: 22361978 DOI: 10.1007/s00415-012-6458-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 02/06/2012] [Accepted: 02/07/2012] [Indexed: 11/30/2022]
Abstract
We assessed the clinicopathological features of nine patients with pure autonomic neuropathy, that is, neuropathy without sensory or motor deficits. The duration from symptom onset to diagnosis ranged from 1 month to 13 years. Of eight patients in whom serum antiganglionic acetylcholine receptor antibody was determined, four were positive. All patients who tested positive for this antibody manifested widespread autonomic dysfunction, with the exception of one patient who only experienced orthostatic hypotension. However, patients who were negative for the antiganglionic acetylcholine receptor antibody presented with partial autonomic failure. One of these patients had diffuse parasympathetic failure and generalized hypohidrosis but no orthostatic hypotension, which is clinically compatible with postganglionic cholinergic dysautonomia. Electron microscopic examination revealed a variable degree of reduction in unmyelinated fibers. Compared with normal controls, the patients had a significantly increased density of collagen pockets (p < 0.05). Additionally, the percentage of Schwann cell subunits with axons (out of the total number of Schwann cell subunits associated with unmyelinated fibers) was significantly decreased (p < 0.01). The density of unmyelinated fibers tended to decrease with increasing time between the onset of autonomic symptoms and biopsy (p < 0.05). In conclusion, the clinical and pathological features of pure autonomic neuropathy vary in terms of progression, autonomic involvement, presence of the antiganglionic acetylcholine receptor antibody, and loss of unmyelinated fibers.
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Affiliation(s)
- Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan.
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Rocchi C, Greco V, Urbani A, Di Giorgio A, Priori M, Massa R, Bernardi G, Marfia GA. Subclinical autonomic dysfunction in spinobulbar muscular atrophy (Kennedy disease). Muscle Nerve 2011; 44:737-40. [PMID: 22006688 DOI: 10.1002/mus.22159] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Spinobulbar muscular atrophy (SBMA) is an inherited adult-onset motor neuron disease caused by the expansion of a polyglutamine tract within the androgen receptor. Autonomic nervous system involvement (ANS) is not considered part of SBMA. The aim of this study was to assess autonomic cardiovascular function in 5 SBMA patients. METHODS Five quantitative autonomic function tests (AFTs) were performed in 5 SBMA patients. Plasma noradrenaline (NA) concentration in patients and in 5 healthy subjects was also measured. RESULTS AFTs were abnormal in 4 of the 5 patients, and plasma NA concentration was significantly reduced in patients with respect to controls. CONCLUSION The impairment of cardiovascular responses to AFTs in addition to reduced plasma NA concentration observed in our patients suggests subclinical involvement of the ANS in Kennedy disease.
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Affiliation(s)
- Camilla Rocchi
- Department of Neuroscience, University of Rome Tor Vergata, 00133 Rome, Italy.
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Abstract
This review of clinical catecholamine neurochemistry is based on the Streeten Memorial Lecture at the 19th annual meeting of the American Autonomic Society and lectures at a satellite of the 6th Congress of the International Society of Autonomic Neuroscience. Here I provide historical perspective, describe sources and meanings of plasma levels of catecholamines and their metabolites, present a model of a sympathetic noradrenergic neuron that conveys how particular aspects of sympathetic nervous function affect plasma levels of catecholamines and their metabolites, and apply the model to understand plasma neurochemical patterns associated with some drugs and disease states.
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Affiliation(s)
- David S Goldstein
- Clinical Neurocardiology Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive MSC-1620, 9000 Rockville Pike, Bldg. 10 Rm. 5N220, Bethesda, MD 20892, USA.
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Hollenbeck R, Black BK, Peltier AC, Biaggioni I, Robertson D, Winton EF, Raj SR. Long-term treatment with rituximab of autoimmune autonomic ganglionopathy in a patient with lymphoma. ACTA ACUST UNITED AC 2010; 68:372-5. [PMID: 21059985 DOI: 10.1001/archneurol.2010.289] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To report on the response to therapy in a patient with autoimmune autonomic ganglionopathy with a high titer of an autoantibody directed against the α-3 subunit of the nicotinic acetylcholine receptor (nAChR) of the autonomic ganglia. DESIGN Case report. SETTING University-based referral center for autonomic dysfunction. PATIENT Patient with prior indolent B-cell lymphoma who presented with symptomatic orthostatic hypotension and autonomic failure and was found to have a high titer of nAChR antibody. INTERVENTION Plasma exchange and rituximab therapy (both initial 4-week therapy and maintenance therapy). MAIN OUTCOME MEASURES Autonomic ganglionic antibody titer; the autonomic assessments were the presence of orthostatic hypotension, the concentration of plasma norepinephrine, and quantitative sweat testing. RESULTS Treatment with rituximab followed by plasma exchange significantly decreased the nAChR antibody titers for a short time, and then the titers increased. The titers suppressed to almost undetectable levels once regular maintenance therapy with rituximab was initiated. Reduction in nAChR antibody titer resulted in a decrease in orthostatic hypotension, an increased concentration of upright plasma norepinephrine, improvement in some sweat function, and improvement in symptoms. CONCLUSIONS Long-term rituximab therapy suppressed autoantibody production to undetectable levels over the course of 2 years and resulted in sustained clinical improvement in this patient with debilitating autoimmune autonomic ganglionopathy. More data are needed before rituximab therapy can be recommended as routine therapy for this disorder.
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Affiliation(s)
- Ryan Hollenbeck
- MSCI, Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, AA3228 Medical Center North, 1161 21st Ave S, Nashville, TN 37232-2195, USA
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