1
|
Latov N, Brannagan TH, Sander HW, Gondim FDAA. Anti-MAG neuropathy: historical aspects, clinical-pathological correlations, and considerations for future therapeutical trials. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-7. [PMID: 38325389 PMCID: PMC10849826 DOI: 10.1055/s-0043-1777728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/21/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Patients with anti-MAG neuropathy present with distal demyelinating polyneuropathy, IgM monoclonal gammopathy, and elevated titers of anti-MAG antibodies. OBJECTIVE This paper reviews what is known about the clinical presentation, course, pathophysiology, and treatment of anti-MAG neuropathy, with considerations for the design of therapeutic trials. METHODS A literature review of the medical and scientific literature related to anti-MAG neuropathy, and the design of therapeutic clinical trials in peripheral neuropathy. RESULTS Anti-MAG neuropathy can remain indolent for many years but then enter a progressive phase. Highly elevated antibody titers are diagnostic, but intermediate titers can also occur in chronic inflammatory demyelinating polyneuropathy (CIDP). The peripheral nerves can become inexcitable, thereby masking the demyelinating abnormalities. There is good evidence that the anti-MAG antibodies cause neuropathy. Reduction of the autoantibody concentration by agents that target B-cells was reported to result in clinical improvement in case series and uncontrolled trials, but not in controlled clinical trials, probably due to inadequate trial design. CONCLUSION We propose that therapeutic trials for anti-MAG neuropathy include patients with the typical presentation, some degree of weakness, highly elevated anti-MAG antibody titers, and at least one nerve exhibiting demyelinating range abnormalities. Treatment with one or a combination of anti-B-cell agents would aim at reducing the autoantibody concentration by at least 60%. A trial duration of 2 years may be required to show efficacy. The neuropathy impairment score of the lower extremities (NIS-LL) plus the Lower Limb Function (LLF) score would be a suitable primary outcome measure.
Collapse
Affiliation(s)
- Norman Latov
- Weil Medical College of Cornell University, Peripheral Neuropathy Center, New York, New York, United States.
| | - Thomas H. Brannagan
- Columbia University, Vagelos College of Physicians and Surgeons, Peripheral Neuropathy Center, Department of Neurology, New York, New York, United States.
| | - Howard W. Sander
- New York University, Department of Neurology, New York, New York, United States.
| | | |
Collapse
|
2
|
Cornejo AC, Latov N. Time course of the autoantibody response to therapy in anti-MAG neuropathy: TWO case REPORTS. Heliyon 2024; 10:e28870. [PMID: 38601656 PMCID: PMC11004559 DOI: 10.1016/j.heliyon.2024.e28870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/12/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
Background Anti-MAG neuropathy is a slowly progressive demyelinating neuropathy that can lead to disability. The neuropathy is thought to be caused by monoclonal IgM antibodies that target the Myelin Associated Glycoprotein (MAG) in peripheral nerves. Therapy is directed at lowering the autoantibody concentrations with B-cells depleting agents, most often rituximab, based on case series and uncontrolled trials reporting improvement. There are no FDA approved treatments for anti-MAG neuropathy, however, and two relatively short duration randomized controlled trials with rituximab failed to achieve their pre-specified primary endpoints. There is also little information regarding the number or duration of treatments that are required to effectively reduce the antibody concentrations. Case presentations We report the time course of the anti-MAG antibody response in two patients with anti-MAG neuropathy that were treated with rituximab for several years. A reduction of 50% in the anti-MAG IgM was seen after 19 and 58 months respectively, and of 70% after 74 or 104 months of treatment respectively. Titres remained low, without evidence of recurrence after the treatments were discontinued. Conclusion Therapy of anti-MAG neuropathy with rituximab may require repeat treatments over more than one year to achieve a significant reduction in autoantibody concentrations. These considerations should inform treatment decisions and the design of clinical trials.
Collapse
Affiliation(s)
| | - Norman Latov
- New York - Presbyterian/Weill Cornell Medicine, USA
| |
Collapse
|
3
|
Elessa D, Grosjean V, Lozeron P, Harel S, Royer B, Forgeard N, Thèves F, Talbot A, Malphettes M, Bengoufa D, Kubis N, Arnulf B. Rituximab with alkylating agent in anti-myelin-associated glycoprotein neuropathy: A retrospective study of 26 cases. Br J Haematol 2024. [PMID: 38500363 DOI: 10.1111/bjh.19412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/05/2024] [Accepted: 03/10/2024] [Indexed: 03/20/2024]
Affiliation(s)
- D Elessa
- Service d'Immuno-Hématologie, Assistance Publique - Hôpitaux de Paris, Hôpital Saint Louis, Paris, France
- Université Paris Cité, Paris, France
| | - V Grosjean
- Université Paris Cité, Paris, France
- Service de Physiologie Clinique-Explorations Fonctionnelles, Assistance Publique - Hôpitaux de Paris, Hôpital Lariboisière, Paris, France
| | - P Lozeron
- Université Paris Cité, Paris, France
- Service de Physiologie Clinique-Explorations Fonctionnelles, Assistance Publique - Hôpitaux de Paris, Hôpital Lariboisière, Paris, France
| | - S Harel
- Service d'Immuno-Hématologie, Assistance Publique - Hôpitaux de Paris, Hôpital Saint Louis, Paris, France
- Université Paris Cité, Paris, France
| | - B Royer
- Service d'Immuno-Hématologie, Assistance Publique - Hôpitaux de Paris, Hôpital Saint Louis, Paris, France
- Université Paris Cité, Paris, France
| | - N Forgeard
- Service d'Immuno-Hématologie, Assistance Publique - Hôpitaux de Paris, Hôpital Saint Louis, Paris, France
- Université Paris Cité, Paris, France
| | - F Thèves
- Service d'Immuno-Hématologie, Assistance Publique - Hôpitaux de Paris, Hôpital Saint Louis, Paris, France
- Université Paris Cité, Paris, France
| | - A Talbot
- Service d'Immuno-Hématologie, Assistance Publique - Hôpitaux de Paris, Hôpital Saint Louis, Paris, France
- Université Paris Cité, Paris, France
| | - M Malphettes
- Université Paris Cité, Paris, France
- Service d'Immuno-pathologie Clinique, Assistance Publique - Hôpitaux de Paris, Hôpital Saint Louis, Paris, France
| | - D Bengoufa
- Université Paris Cité, Paris, France
- Laboratoire d'Immunologie, Assistance Publique - Hôpitaux de Paris, Hôpital Saint Louis, Paris, France
| | - N Kubis
- Université Paris Cité, Paris, France
- Service de Physiologie Clinique-Explorations Fonctionnelles, Assistance Publique - Hôpitaux de Paris, Hôpital Lariboisière, Paris, France
| | - B Arnulf
- Service d'Immuno-Hématologie, Assistance Publique - Hôpitaux de Paris, Hôpital Saint Louis, Paris, France
- Université Paris Cité, Paris, France
| |
Collapse
|
4
|
Guérémy A, Boucraut J, Boudjarane J, Grapperon AM, Fortanier E, Farnault L, Gabert J, Vely F, Lacroix R, Kouton L, Attarian S, Delmont E. Clinical, biological, electrophysiological and therapeutic profile of patients with anti-MAG neuropathy according to MYD88 L265P and CXCR4 mutations and underlying haemopathy. J Neurol 2024; 271:1320-1330. [PMID: 37979093 DOI: 10.1007/s00415-023-12068-4] [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: 07/26/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Anti-MAG neuropathies are associated with an IgM monoclonal gammopathy of undetermined significance (MGUS) or with a malignant haemopathy. Our objective was to determine whether the presence of a haemopathy or somatic mutations of MYD88 and CXCR4 genes influences disease presentation and response to rituximab (RTX). METHODS We included 79 patients (mean age 74 years, disease duration 9.68 years) who had a bone marrow aspiration with morphologic and immunophenotypic analysis. MYD88L265P and CXCR4 mutations were analysed in peripheral B cells. Information collected included: inflammatory neuropathy cause and treatment sensory sum score (ISS), MRC testing, overall neuropathy limitation scale (ONLS), Rash-built Overall Disability Score (RODS), ataxia score, anti-MAG titres, peak IgM dosage, neurofilament light chain levels, motor and sensory amplitudes, motor unit index (MUNIX) and motor unit size index (MUSIX) sum scores. Efficacy of RTX was evaluated at 12 months in 26 patients. RESULTS Malignant haematological disorders were discovered in 17 patients (22%): 13 Waldenstrom macroglobulinemia, 3 marginal zone lymphoma and one mantle cell lymphoma. MYD88L265P mutation was detected in 29/60 (48%) patients and CXCR4 in 1 single patient. Disease severity, biological and electrophysiological data and response to RTX were comparable in patients with MGUS/lymphoma and patients with/without MYD88L265P mutation. ISS was lower and MUSIX higher in patients improved by RTX. CONCLUSIONS MYD88L265P mutation and underlying haemopathies are not predictive of a more severe disease. However, in cases of resistant and progressive neuropathy, they provide an opportunity to prescribe newly available drugs such as Bruton tyrosine kinase inhibitors.
Collapse
Affiliation(s)
- Alexandre Guérémy
- Referral Centre for Neuromuscular Diseases and ALS, Hospital La Timone, 264 Rue Saint Pierre, 13005, Marseille, France
| | - José Boucraut
- APHM, Hôpital de La Timone, Service d'Immunologie, Marseille-Immunopole, Marseille, France
- AMU, Institut de Neurosciences des Systèmes (INS, UMR1106), Marseille, France
| | - John Boudjarane
- Laboratory of Constitutional Cytogenetics, Department of Medical Genetics, La Timone Hospital Marseille, Marseille, France
| | - Aude-Marie Grapperon
- Referral Centre for Neuromuscular Diseases and ALS, Hospital La Timone, 264 Rue Saint Pierre, 13005, Marseille, France
| | - Etienne Fortanier
- Referral Centre for Neuromuscular Diseases and ALS, Hospital La Timone, 264 Rue Saint Pierre, 13005, Marseille, France
| | - Laure Farnault
- Haematology and Cellular Therapy Department, La Conception, University Hospital of Marseille, Marseille, France
- APHM Head of Biochemistry and Molecular Biology, Hopital Nord chemin des Bourrely, 13015, Marseille, France
| | - Jean Gabert
- INT Bd Jean Moulin Aix-Marseille University UMR7289, Marseille, France
- Aix-Marseille University, CNRS, INSERM, CIML, Marseille, France
| | - Frédéric Vely
- APHM, Hôpital de La Timone, Service d'Immunologie, Marseille-Immunopole, Marseille, France
- Aix-Marseille University, CNRS, INSERM, CIML, Marseille, France
| | - Romaric Lacroix
- Center for CardioVascular and Nutrition Research (C2VN), Faculty of Medical and Paramedical Sciences, Aix-Marseille University, National Institute of Health and Medical Research (INSERM), National Research Institute for Agriculture, Food and Environment (INRAE), 13005, Marseille, France
- Laboratoire d'Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Ludivine Kouton
- Referral Centre for Neuromuscular Diseases and ALS, Hospital La Timone, 264 Rue Saint Pierre, 13005, Marseille, France
| | - Shahram Attarian
- Referral Centre for Neuromuscular Diseases and ALS, Hospital La Timone, 264 Rue Saint Pierre, 13005, Marseille, France
| | - Emilien Delmont
- Referral Centre for Neuromuscular Diseases and ALS, Hospital La Timone, 264 Rue Saint Pierre, 13005, Marseille, France.
| |
Collapse
|
5
|
Min YG, Han HJ, Shin HY, Baek JG, Kim JS, Park KS, Baek SH, Yoo I, Huh SY, Kwon YN, Choi SJ, Kim SM, Hong YH, Sung JJ. Therapeutic Outcomes and Electrophysiological Biomarkers in Anti-Myelin-Associated Glycoprotein Neuropathy: A Multicenter Cohort Study in South Korea. J Clin Neurol 2024; 20:50-58. [PMID: 38179632 PMCID: PMC10782088 DOI: 10.3988/jcn.2023.0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/04/2023] [Accepted: 06/07/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Unlike other immune-mediated neuropathies, anti-myelin-associated glycoprotein (MAG) neuropathy is often refractory to immunotherapy. It is necessary to compare the relative efficacies of various immunotherapies and develop objective biomarkers in order to optimize its clinical management. METHODS This study recruited 91 patients with high anti-MAG antibody titers from 7 tertiary hospitals in South Korea. We analyzed the baseline characteristics, therapeutic outcomes, and nerve conduction study (NCS) findings of 68 patients and excluded 23 false positive cases. RESULTS The rate of positive responses to treatment was highest using zanubrutinib (50%) and rituximab (36.4%), followed by corticosteroids (16.7%), immunosuppressants (9.5%), intravenous immunoglobulin (5%), and plasma exchange (0%). Disability and weakness were significantly associated with multiple NCS parameters at the time of diagnosis, especially distal compound muscle action potential (CMAP) amplitudes. Moreover, the longitudinal trajectory of the average CMAP amplitudes paralleled the clinical courses, with a 16.2 percentile decrease as an optimal cutoff for predicting a clinical exacerbation (area under the receiver operating characteristic curve=0.792). CONCLUSIONS Our study supports the use of NCS as an objective marker for estimating disease burden and tracking clinical changes in patients with anti-MAG neuropathy. We have described the beneficial effects of rituximab and a new drug, zanubrutinib, compared with conventional immunotherapies.
Collapse
Affiliation(s)
- Young Gi Min
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Hee-Jo Han
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong-Gyu Baek
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jun-Soon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyung-Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seol-Hee Baek
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Ilhan Yoo
- Department of Neurology, Nowon Eulji Medical Center, Seoul, Korea
| | - So-Young Huh
- Department of Neurology, Kosin Medical University Hospital, Busan, Korea
| | - Young Nam Kwon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Seok-Jin Choi
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Sung-Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Yoon-Ho Hong
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jung-Joon Sung
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
- Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Korea.
| |
Collapse
|
6
|
Mariotto S, de Gaspari P, Jäger D, Hahn S, Forni C, Saschenbrecker S, Lattwein E, Dinoto A, Ferrari S. A novel cell-based immunofluorescence assay for the detection of autoantibodies to myelin-associated glycoprotein. Front Neurol 2023; 14:1289810. [PMID: 38169815 PMCID: PMC10758835 DOI: 10.3389/fneur.2023.1289810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024] Open
Abstract
Peripheral neuropathy with antibodies to myelin-associated glycoprotein (MAG) is an autoimmune demyelinating disorder of the peripheral nervous system caused by pathogenic IgM recognizing the human natural killer-1 glycoepitope expressed on MAG. This study aimed to analyze the performance of a new indirect immunofluorescence cell-based assay (CBA, EUROIMMUN) for the detection of anti-MAG IgM. Antibody reactivity was determined in sera from 95 patients with clinical and neurophysiological evidence of anti-MAG-associated neuropathy and in control samples from 55 patients with other forms of peripheral neuropathy. Compared to the results of the gold standard method (ELISA, Bühlmann) and using samples at a dilution of 1:100, the CBA had a sensitivity of 98.9% and a specificity of 100% (PPV 100%, NPV 98.2%). In conclusion, the CBA allows the detection of antibodies to MAG using an easy and standardized technique, and it presents a sensitive and specific alternative to the more time-consuming ELISA. Larger studies are needed to address anti-MAG titer monitoring in parallel with clinical activity.
Collapse
Affiliation(s)
- Sara Mariotto
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Piera de Gaspari
- Neuroimmunology Group, Pediatric Research Institute, Padua, Italy
| | - Dominik Jäger
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Stefanie Hahn
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Cindy Forni
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Sandra Saschenbrecker
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Erik Lattwein
- Institute for Experimental Immunology, affiliated to EUROIMMUN Medizinische Labordiagnostika AG, Lübeck, Germany
| | - Alessandro Dinoto
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Sergio Ferrari
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| |
Collapse
|
7
|
Stino AM, Elsheikh B, Allen JA. Anti-myelin-associated glycoprotein neuropathy: Where do we stand? Muscle Nerve 2023; 68:823-832. [PMID: 37602932 DOI: 10.1002/mus.27954] [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: 05/09/2023] [Revised: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 08/22/2023]
Abstract
Myelin-associated glycoprotein (MAG) is a transmembrane glycoprotein concentrated in periaxonal Schwann cell and oligodendroglial membranes of myelin sheaths that serves as an antigen for immunoglobulin M (IgM) monoclonal antibodies. Individuals who harbor anti-MAG antibodies classically develop a progressive autoimmune peripheral neuropathy characterized clinically by ataxia, distal sensory loss, and gait instability, and electrophysiologically by distally accentuated conduction velocity slowing. Although off-label immunotherapy is common, there are currently no proven effective disease-modifying therapeutics, and most patients experience slow accumulation of disability over years and decades. The typically slowly progressive nature of this neuropathy presents unique challenges when trying to find effective anti-MAG therapeutic agents. Drug development has also been hampered by the lack of validated outcome measures that can detect clinically meaningful changes in a reasonable amount of time as well as by the lack of disease activity biomarkers. In this invited review, we provide an update on the state of clinicometric outcome measures and disease activity biomarkers in anti-MAG neuropathy. We highlight the insensitivity of widely used existing clinicometric outcome measures such as the Inflammatory Neuropathy Cause and Treatment (INCAT) disability score as well as the INCAT sensory subscore in anti-MAG neuropathy, referencing the two previous negative randomized controlled clinical trials evaluating rituximab. We then discuss newly emerging candidate therapeutic agents, including tyrosine kinase inhibitors and enhanced B-cell-depleting agents, among others. We conclude with a practical approach to the evaluation and management of anti-MAG neuropathy patients.
Collapse
Affiliation(s)
- Amro Maher Stino
- Department of Neurology, Division of Neuromuscular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Bakri Elsheikh
- Department of Neurology, Division of Neuromuscular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jeffrey A Allen
- Department of Neurology, Division of Neuromuscular Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
8
|
Beydoun SR, Darki L. Paraproteinemic Neuropathies. Continuum (Minneap Minn) 2023; 29:1492-1513. [PMID: 37851040 DOI: 10.1212/con.0000000000001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Coexistence of polyneuropathy and gammopathy is a common but potentially challenging situation in clinical practice. This article reviews the clinical, electrophysiologic, and hematologic phenotypes of the paraproteinemic neuropathies and the diagnostic and treatment strategies for each. LATEST DEVELOPMENTS Advances in our understanding of the underlying pathophysiology of various paraproteinemic neuropathies and their corresponding phenotypes have identified potential new therapeutic targets. Therapeutic strategies to diminish anti-myelin-associated glycoprotein (MAG) IgM antibodies have shown partial and inconsistent efficacy; however, antigen-specific immune therapy is being investigated as a novel treatment to remove the presumably pathogenic anti-MAG antibody. Advances in genetic and cell signaling studies have resulted in the approval of Bruton tyrosine kinase inhibitors for Waldenström macroglobulinemia. Monoclonal antibodies are being investigated for the treatment of light chain amyloidosis. ESSENTIAL POINTS Early recognition and treatment of underlying plasma cell disorders improves clinical outcomes in patients with paraproteinemic neuropathy. Despite significant progress, our knowledge regarding underlying mechanisms for paraproteinemic neuropathy is still limited. Clinicians' awareness of clinical phenotypes, electrophysiologic hallmarks, and hematologic findings of the different paraproteinemic neuropathies is crucial to promptly identify and treat patients and to avert misdiagnosis. Multidisciplinary collaboration among specialists, including neurologists and hematologists, is paramount for the optimal treatment of these patients with overlapping conditions.
Collapse
|
9
|
Tomkins O, Leblond V, Lunn MP, Viala K, Weil DR, D'Sa S. Investigation and Management of Immunoglobulin M- and Waldenström-Associated Peripheral Neuropathies. Hematol Oncol Clin North Am 2023; 37:761-776. [PMID: 37385714 DOI: 10.1016/j.hoc.2023.04.007] [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: 07/01/2023]
Abstract
The immunoglobulin M (IgM)-associated peripheral neuropathies (PN) are a heterogeneous group of disorders representing most paraproteinemic neuropathy cases. They are associated with IgM monoclonal gammopathy of undetermined significance (MGUS) or Waldenström macroglobulinemia. Establishing a causal link between a paraprotein and neuropathy can be challenging but is necessary to adopt an appropriate therapeutic approach. The most common type of IgM-PN is Antimyelin-Associated-Glycoprotein neuropathy, but half of the cases are of other causes. Progressive functional impairment is an indication for treatment, even when the underlying disorder is IgM MGUS, involving either rituximab monotherapy or combination chemotherapy to achieve clinical stabilization.
Collapse
Affiliation(s)
- Oliver Tomkins
- Department of Haematology, Centre for Waldenströms Macroglobulinaemia and Related Conditions, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK. https://twitter.com/tomkinsoliver
| | - Veronique Leblond
- Department of Haematology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Michael P Lunn
- National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Karine Viala
- Department of Clinical Neurophysiology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Damien Roos Weil
- Department of Haematology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Shirley D'Sa
- Department of Haematology, Centre for Waldenströms Macroglobulinaemia and Related Conditions, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| |
Collapse
|
10
|
Value of Antibody Determinations in Chronic Dysimmune Neuropathies. Brain Sci 2022; 13:brainsci13010037. [PMID: 36672019 PMCID: PMC9856104 DOI: 10.3390/brainsci13010037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/12/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
Chronic dysimmune neuropathies encompass a group of neuropathies that share immune-mediated pathomechanism. Chronic dysimmune antibody-related neuropathies include anti-MAG neuropathy, multifocal motor neuropathy, and neuropathies related to immune attack against paranodal antigens. Such neuropathies exhibit distinguishing pathomechanism, clinical and response to therapy features with respect to chronic inflammatory demyelinating polyradiculoneuropathy and its variants, which represent the most frequent form of chronic dysimmune neuropathy. This narrative review provides an overview of pathomechanism; clinical, electrophysiological, and biochemical features; and treatment response of the antibody-mediated neuropathies, aiming to establish when and why to look for antibodies in chronic dysimmune neuropathies.
Collapse
|
11
|
Briani C, Cocito D, Campagnolo M, Doneddu PE, Nobile-Orazio E. Update on therapy of chronic immune-mediated neuropathies. Neurol Sci 2022; 43:605-614. [PMID: 33452933 DOI: 10.1007/s10072-020-04998-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/12/2020] [Indexed: 12/27/2022]
Abstract
Chronic immune-mediated neuropathies, including chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), neuropathies associated with monoclonal gammopathy, and multifocal motor neuropathy (MMN), are a group of disorders deemed to be caused by an immune response against peripheral nerve antigens. Several immune therapies have been reported to be variably effective in these neuropathies including steroids, plasma exchange, and high-dose intravenous (IVIg) or subcutaneous (SCIg) immunoglobulins. These therapies are however far from being invariably effective and may be associated with a number of side effects leading to the use of immunosuppressive agents whose efficacy has not been so far confirmed in randomized trials. More recently, new biological agents, such as rituximab, have proved to be effective in patients with neuropathy associated with IgM monoclonal gammopathy and are currently tested in CIDP.
Collapse
Affiliation(s)
- Chiara Briani
- Neurology Unit, Department of Neuroscience, University of Padova, Via Giustiniani, 5, 35128, Padova, Italy.
| | - Dario Cocito
- Istituti Clinici Scientifici Maugeri, Torino, Italy
| | - Marta Campagnolo
- Neurology Unit, Department of Neuroscience, University of Padova, Via Giustiniani, 5, 35128, Padova, Italy
| | - Pietro Emiliano Doneddu
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Institute, Rozzano, Milan, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical and Research Institute, Rozzano, Milan, Italy.,Department of Medical Biotechnology and Translational Medicine, Milan University, Milan, Italy
| |
Collapse
|
12
|
Polyneuropathy Associated with IgM Monoclonal Gammopathy; Advances in Genetics and Treatment, Focusing on Anti-MAG Antibodies. HEMATO 2022. [DOI: 10.3390/hemato3040045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
With increasing age, the chances of developing either MGUS or polyneuropathy increase as well. In some cases, there is a causative relationship between the IgM M-protein and polyneuropathy. In approximately half of these cases, IgM targets the myelin-associated glycoprotein (MAG). This results in chronic polyneuropathy with slowly progressive, predominantly sensory neurological deficits and distally demyelinating features in nerve conduction studies. Despite the disease being chronic and developing slowly, it can cause considerable impairment. We reviewed English medical publications between 1980 and May 2022 on IgM gammopathy-associated polyneuropathy, with special attention to studies addressing the pathophysiology or treatment of anti-MAG polyneuropathy. Treatment options have been limited to a temporizing effect of intravenous immunoglobulins in some patients and a more sustained effect of rituximab but in only 30 to 55 percent of patients. An increase in our knowledge concerning genetic mutations, particularly the MYD88L265P mutation, led to the development of novel targeted treatment options such as BTK inhibitors. Similarly, due to the increasing knowledge of the pathophysiology of anti-MAG polyneuropathy, new treatment options are emerging. Since anti-MAG polyneuropathy is a rare disease with diverse symptomatology, large trials with good outcome measures are a challenge.
Collapse
|
13
|
Movement disorders and neuropathies: overlaps and mimics in clinical practice. J Neurol 2022; 269:4646-4662. [PMID: 35657406 DOI: 10.1007/s00415-022-11200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 10/18/2022]
Abstract
Movement disorders as well as peripheral neuropathies are extremely frequent in the general population; therefore, it is not uncommon to encounter patients with both these conditions. Often, the coexistence is coincidental, due to the high incidence of common causes of peripheral neuropathy, such as diabetes and other age-related disorders, as well as of Parkinson disease (PD), which has a typical late onset. Nonetheless, there is broad evidence that PD patients may commonly develop a sensory and/or autonomic polyneuropathy, triggered by intrinsic and/or extrinsic mechanisms. Similarly, some peripheral neuropathies may develop some movement disorders in the long run, such as tremor, and rarely dystonia and myoclonus, suggesting that central mechanisms may ensue in the pathogenesis of these diseases. Although rare, several acquired or hereditary causes may be responsible for the combination of movement and peripheral nerve disorders as a unique entity, some of which are potentially treatable, including paraneoplastic, autoimmune and nutritional aetiologies. Finally, genetic causes should be pursued in case of positive family history, young onset or multisystemic involvement, and examined for neuroacanthocytosis, spinocerebellar ataxias, mitochondrial disorders and less common causes of adult-onset cerebellar ataxias and spastic paraparesis. Deep phenotyping in terms of neurological and general examination, as well as laboratory tests, neuroimaging, neurophysiology, and next-generation genetic analysis, may guide the clinician toward the correct diagnosis and management.
Collapse
|
14
|
Nivet T, Baptiste A, Belin L, Ghillani-Dalbin P, Algrin C, Choquet S, Lamy T, Morel V, Musset L, Roos-Weil D, Viala K, Leblond V, Baron M. Immunochemotherapy versus rituximab in anti-myelin-associated glycoprotein neuropathy: A report of 64 patients. Br J Haematol 2022; 198:298-306. [PMID: 35420717 DOI: 10.1111/bjh.18202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 01/22/2023]
Abstract
Monoclonal immunoglobulin M (IgM) anti-myelin-associated glycoprotein (MAG) neuropathy is a rare disabling condition, most commonly treated with rituximab monotherapy (R), which leads to neurological improvement in only 30%-50% of patients. The combination of rituximab plus chemotherapy has been proven to improve the level of responses. We studied the outcomes of anti-MAG neuropathy patients treated either by R, or by immunochemotherapy (ICT) in our centre, focusing on the incidence of the first neurological response evaluated by the modified Rankin scale (mRS). From 2011 to 2018, 64 patients were studied: 34 were treated with R and 30 with ICT. According to our treatment decision-making process, the median mRS was higher in the ICT group (mRS 2) than in the R group (mRS 1). At one year, improvements of the mRS rates were 46% and 18% in the ICT and R groups of patients respectively, with median times to response of eight and 13 months (p = 0.023). Adverse effects were higher in the ICT group: 62% vs 15% (p ˂ 0.01), all grades included. One secondary acute leukaemia occurred five years after treatment with ICT. In conclusion, ICT may be used as a valid option for patients with rapidly progressive and/or severe anti-MAG neuropathy symptoms.
Collapse
Affiliation(s)
- Thomas Nivet
- Department of Hematology, AP-HP, Sorbonne Université, Pitié- Salpêtrière Hospital, Paris, France.,Department of Hematology, CHU de Rennes, Rennes, France
| | - Amandine Baptiste
- Department of Epidemiology, Biostatistics and Clinical Research, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Lisa Belin
- Department of Epidemiology, Biostatistics and Clinical Research, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Pascale Ghillani-Dalbin
- Department of Immunochemistry, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Caroline Algrin
- Department of Hematology, Groupe Hospitalier mutualiste de Grenoble, Grenoble, France
| | - Sylvain Choquet
- Department of Hematology, AP-HP, Sorbonne Université, Pitié- Salpêtrière Hospital, Paris, France
| | - Thierry Lamy
- Department of Hematology, CHU de Rennes, Rennes, France
| | - Véronique Morel
- Department of Hematology, AP-HP, Sorbonne Université, Pitié- Salpêtrière Hospital, Paris, France
| | - Lucile Musset
- Department of Immunochemistry, AP-HP, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Damien Roos-Weil
- Department of Hematology, AP-HP, Sorbonne Université, Pitié- Salpêtrière Hospital, Paris, France
| | - Karine Viala
- Department of Neurophysiology, AP-HP, Sorbonne Université, Pitié- Salpêtrière Hospital, Paris, France
| | - Véronique Leblond
- Department of Hematology, AP-HP, Sorbonne Université, Pitié- Salpêtrière Hospital, Paris, France
| | - Marine Baron
- Department of Hematology, AP-HP, Sorbonne Université, Pitié- Salpêtrière Hospital, Paris, France
| |
Collapse
|
15
|
Briani C, Visentin A. Therapeutic Monoclonal Antibody Therapies in Chronic Autoimmune Demyelinating Neuropathies. Neurotherapeutics 2022; 19:874-884. [PMID: 35349079 PMCID: PMC9294114 DOI: 10.1007/s13311-022-01222-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 02/07/2023] Open
Abstract
Autoimmune diseases of the peripheral nervous system have so far been treated mainly with exogenous high-dose intravenous immunoglobulins (IVIg), that act through several mechanisms, including neutralization of pathogenic autoantibodies, modulation of lymphocyte activity, interference with antigen presentation, and interaction with Fc receptors, cytokines, and the complement system. Other therapeutic strategies have recently been developed, in part to address the increasing shortage of IVIg, prime among which is the use of B cell depleting monoclonal antibodies, or small molecule inhibitors targeting the B-cell specific kinases. Rituximab, a chimeric monoclonal antibody against CD20 + B lymphocytes, is currently the most used, especially in anti-MAG antibody neuropathy and autoimmune neuropathies with antibodies to nodal/paranodal antigens that are unresponsive to IVIg. After several reports of its efficacy in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), rituximab is currently under investigation in three Phase 2 trials in CIDP. In addition, the possible role of complement activation in the pathogenesis of chronic autoimmune neuropathies has brought into consideration drugs that can block the complement cascade, such as eculizumab, a monoclonal antibody already assessed in acute polyradiculoneuropathies, and approved for myasthenia gravis. Preliminary data on eculizumab in multifocal motor neuropathy have been published, but randomized controlled studies are pending. Moreover, the neonatal Fc receptor, that recycles IgGs by preventing their lysosome degradation, is an important and attractive pharmacological target. Antibodies against FcRn, which reduce circulating IgG (both pathogenic and non-pathogenic) have been developed. The FcRn blocker efgartigimod, a humanized IgG1-derived Fc fragment, which competitively inhibits the FcRn, has recently been approved for the treatment of myasthenia gravis and is currently under investigation in CIDP. In addition, the anti-human FcRn monoclonal antibody rozanolixizumab is currently being assessed in phase 2 trials in CIDP. However, none of the abovementioned monoclonal antibodies is currently approved for treatment of any immune-mediated neuropathies. While more specific and individualized therapies are being developed, the possibility of combined treatments targeting different pathogenic mechanisms deserves consideration as well.
Collapse
Affiliation(s)
- Chiara Briani
- Department of Neurosciences, Neurology Unit, University of Padova, Padova, Italy.
| | - Andrea Visentin
- Department of Medicine, Hematology Unit, University of Padova, Padova, Italy
| |
Collapse
|
16
|
Anti-MAG neuropathy: From biology to clinical management. J Neuroimmunol 2021; 361:577725. [PMID: 34610502 DOI: 10.1016/j.jneuroim.2021.577725] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/20/2021] [Indexed: 12/19/2022]
Abstract
The acquired chronic demyelinating neuropathies include a growing number of disease entities that have characteristic, often overlapping, clinical presentations, mediated by distinct immune mechanisms, and responding to different therapies. After the discovery in the early 1980s, that the myelin associated glycoprotein (MAG) is a target antigen in an autoimmune demyelinating neuropathy, assays to measure the presence of anti-MAG antibodies were used as the basis to diagnose the anti-MAG neuropathy. The route was open for describing the clinical characteristics of this new entity as a chronic distal large fiber sensorimotor neuropathy, for studying its pathogenesis and devising specific treatment strategies. The initial use of chemotherapeutic agents was replaced by the introduction in the late 1990s of rituximab, a monoclonal antibody against CD20+ B-cells. Since then, other anti-B cells agents have been introduced. Recently a novel antigen-specific immunotherapy neutralizing the anti-MAG antibodies with a carbohydrate-based ligand mimicking the natural HNK-1 glycoepitope has been described.
Collapse
|
17
|
Abstract
Paraproteinaemic neuropathies comprise a heterogeneous group of neuro-haematological conditions with some distinct neurological, haematological and systemic phenotypes. The spectrum of disease varies from mild to severe, indolent to rapidly progressive and from small fibre sensory involvement to dramatic sensorimotor deficits. The haematological association may be overlooked, resulting in delayed treatment, disability, impaired quality of life and increased mortality. However, the presence of an irrelevant benign paraprotein can sometimes lead to inappropriate treatment. In this review, we outline our practical approach to paraproteinaemic disorders, discuss the utility and limitations of diagnostic tests and the distinctive clinical phenotypes and touch on the complex multidisciplinary management approaches.
Collapse
Affiliation(s)
- Antonia S Carroll
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia.,National Hospital for Neurology and Neurosurgery, London, UK
| | | |
Collapse
|
18
|
Castillo JJ, Callander NS, Baljevic M, Sborov DW, Kumar S. The evaluation and management of monoclonal gammopathy of renal significance and monoclonal gammopathy of neurological significance. Am J Hematol 2021; 96:846-853. [PMID: 33709474 PMCID: PMC8252623 DOI: 10.1002/ajh.26155] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/07/2021] [Indexed: 12/24/2022]
Abstract
Despite the benign nature of monoclonal gammopathy of undetermined significance (MGUS), mounting data are associating MGUS with the development of organ dysfunction, specifically monoclonal gammopathy of renal significance (MGRS) and monoclonal gammopathy of neurological significance (MGNS), which could be associated with substantial morbidity. Emerging evidence suggests that patients with MGRS and MGNS could benefit from treatments used for myeloma, Waldenström macroglobulinemia, or chronic lymphocytic leukemia, depending on the underlying pathology. However, the treatment of MGRS and MGNS is not standardized, and potentially effective therapies might not be reimbursed because these conditions do not formally meet the criteria for malignant processes. The present review aims at establishing standards for the evaluation and management of MGRS and MGNS, which can facilitate the diagnosis of and provide therapeutic options for treating practitioners and patients affected by these conditions. The careful design and execution of clinical trials for patients with MGRS and MGNS are positively encouraged.
Collapse
Affiliation(s)
- Jorge J. Castillo
- Dana‐Farber Cancer Institute Harvard Medical School Boston Massachusetts
| | | | | | | | | |
Collapse
|
19
|
Matà S, Torricelli S, Barilaro A, Grippo A, Forleo P, Del Mastio M, Sorbi S. Polyneuropathy and monoclonal gammopathy of undetermined significance (MGUS); update of a clinical experience. J Neurol Sci 2021; 423:117335. [PMID: 33647732 DOI: 10.1016/j.jns.2021.117335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Polyneuropathies associated with monoclonal gammopathy of undetermined significance (MGUS) encompass a group of phenotypically and immunologically heterogeneous neuropathies. While the best characterized is that associated with anti-myelin glycoprotein (MAG) antibodies, there are phenotypical and immunological neuropathy variants that still lack a clear classification. We analyzed a significant number of patients, in order to better evaluate the distribution of neuropathy phenotypes and to look for some common characteristics. METHODS Clinical, neurophysiological, and laboratory data from 87 consecutive MGUS patients with peripheral neuropathy were analyzed and compared among patient groups with different MGUS classes and autoantibody reactivity. RESULTS Anti-MAG neuropathy cases account for the most homogeneous group with regard to clinical and neurophysiological findings. Patients with anti-gangliosides or sulfatide (GS) antibodies, despite a marked phenotype heterogeneity, still share several common features, including a younger age at diagnosis, a more severe disease, and a prompt and sustained response to both immunoglobulin and rituximab therapies, mostly requiring chronic administration of immune treatment. CONCLUSIONS Although heterogeneous, MGUS-associated, anti-GS antibody positive neuropathies have important similar features possibly resulting from a similar biological background.
Collapse
Affiliation(s)
- Sabrina Matà
- SOD Neurologia 1, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Sara Torricelli
- Department of Neuroscience, Psychology, Drug Research and Child Health and Centro di Ricerca, University of Florence, Florence, Italy.
| | - Alessandro Barilaro
- SOD Neurologia 2, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Antonello Grippo
- SOD Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Paolo Forleo
- SOD Neurologia 1, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Monica Del Mastio
- SOD Neurologia 1, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Sandro Sorbi
- Department of Neuroscience, Psychology, Drug Research and Child Health and Centro di Ricerca, University of Florence, Florence, Italy; IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.
| |
Collapse
|
20
|
Tuchman SA, Zonder JA. The Spectrum of Monoclonal Immunoglobulin-Associated Diseases. Hematol Oncol Clin North Am 2020; 34:997-1008. [PMID: 33099435 DOI: 10.1016/j.hoc.2020.07.002] [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: 11/16/2022]
Abstract
The spectrum of immunoglobulin paraprotein-associated diseases requiring therapy extends beyond multiple myeloma and AL amyloidosis. Awareness of these is essential in ensuring timely accurate diagnosis and appropriate treatment. As most paraprotein-associated diseases are fairly uncommon, therapeutic decisions must often be made in the absence of data from randomized controlled trials. Treatment is generally directed at the underlying clonal cell population. This review focuses on the spectrum of the less common paraprotein-associated disorders. In most instances, the monoclonal immunoglobulin plays a direct role in the pathophysiology of the disease course; in a select few, the paraprotein may be a disease marker.
Collapse
Affiliation(s)
- Sascha A Tuchman
- Division of Hematology, University of North Carolina - Chapel Hill, Comprehensive Cancer Center, 170 Manning Dr., CB#7305, Chapel Hill, NC 27599, USA
| | - Jeffrey A Zonder
- Barbara Ann Karmanos Cancer Institute/Wayne State University School of Medicine, Myeloma and Amyloidosis Team, Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA.
| |
Collapse
|
21
|
Association of variability in antibody binding affinity with a clinical course of anti-MAG neuropathy. J Neuroimmunol 2020; 339:577127. [PMID: 31841738 DOI: 10.1016/j.jneuroim.2019.577127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/08/2019] [Accepted: 12/09/2019] [Indexed: 11/23/2022]
Abstract
Anti-myelin-associated glycoprotein (MAG) neuropathy is mediated by the binding of IgM M-proteins to the human natural killer-1 epitope of several glycoconjugates, including MAG and phosphacan. We recently reported that IgM M-proteins with a higher ratio of anti-phosphacan titer to anti-MAG titer (P/M ratio) were associated with a progressive clinical course. Herein, we investigated the temporal variability of the P/M ratio. The results showed that P/M ratios in worsened cases were significantly increased relative to stable or improved cases. Thus, temporal variability in the specificity of IgM M-proteins may be related to the disease course of anti-MAG neuropathy.
Collapse
|
22
|
Tang MAH, Mathis S, Duffau P, Cazenave P, Solé G, Duval F, Soulages A, Le Masson G. Prognostic factor of poor outcome in anti-MAG neuropathy: clinical and electrophysiological analysis of a French Cohort. J Neurol 2019; 267:561-571. [PMID: 31705291 DOI: 10.1007/s00415-019-09618-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/01/2019] [Accepted: 11/02/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti-MAG polyneuropathy (anti-MAG PN) is an immune-mediated peripheral sensorimotor neuropathy characterized by distal demyelination and ataxia. However, this disorder, unlike other immune-mediated neuropathies, is difficult to treat in most cases. METHOD We retrospectively collected all anti-MAG PN patients followed in two hospitals for a period of 12 years to determine prognostic factors, especially those that indicated a good response to the various therapeutic strategies used. RESULTS Forty-seven patients were included in the study; of these, 61% had a classical 'distal demyelinating pattern', 34.2% had a 'CIDP-like pattern', and the others had an 'axonal pattern'. The most commonly used treatments were intravenous immunoglobulin (IVIg) as the first-line treatment and rituximab as the second- or third-line treatment. No prognostic factor was identified for IVIg, but electrophysiological parameters at onset were better in patients with a good response to rituximab than in non-responder patients, even though mild or high disability was observed in nearly half the patients at last examination. CONCLUSION Even though disability seems to progress in most cases despite the treatments used, our results suggest that an early electrophysiological reduction in sensory nerves could be considered a 'red flag' for the prompt initiation of rituximab to try to delay long-term disability.
Collapse
Affiliation(s)
- Marie-Ange Hoang Tang
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Stéphane Mathis
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France.,Centre de Référence des Pathologies Neuromusculaires, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Pierre Duffau
- Department of Internal Medicine and Clinical Immunology, CHU Bordeaux (Groupe Hospitalier Saint-André), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Philippe Cazenave
- Department of Neurology, Robert Boulin Hospital, 112 rue de la Marne, 33505, Libourne, France
| | - Guilhem Solé
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France.,Centre de Référence des Pathologies Neuromusculaires, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Fanny Duval
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France.,Centre de Référence des Pathologies Neuromusculaires, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Antoine Soulages
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Gwendal Le Masson
- Department of Neurology, Nerve-Muscle Unit, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France. .,Centre de Référence des Pathologies Neuromusculaires, CHU Bordeaux (Groupe Hospitalier Pellegrin), University of Bordeaux, Place Amélie Raba-Léon, 33000, Bordeaux, France.
| |
Collapse
|
23
|
|
24
|
Campagnolo M, Ruiz M, Falzone YM, Ermani M, Bianco M, Martinelli D, Cerri F, Quattrini A, Salvalaggio A, Castellani F, Comi G, Giannini F, Nobile-Orazio E, Fazio R, Riva N, Briani C. Limitations in daily activities and general perception of quality of life: Long term follow-up in patients with anti-myelin-glycoprotein antibody polyneuropathy. J Peripher Nerv Syst 2019; 24:276-282. [PMID: 31397934 DOI: 10.1111/jns.12342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/22/2019] [Accepted: 08/02/2019] [Indexed: 12/01/2022]
Abstract
In this study, we assessed the modifications over time of daily activities and quality of life (QoL) in 32 subjects with anti-myelin-glycoprotein (MAG) antibody neuropathy. A widespread panel including clinical scores and patient-reported questionnaires, in compliance of the terms by the International Classification of Functioning, Disability, and Health (ICF) of the World Health Organization (WHO), was employed at enrollment (T0) and at follow-up evaluation (T1) after a mean interval of 15.4 ± 5.7 months. The Sensory Modality Sum score (SMS) at four limbs showed a significant worsening over time (mean score 27.2 ± 3.9 at T0 vs 25.7 ± 3 at T1 at upper limbs, P = .03; 20.5 ± 4.8 at T0 vs 18.6 ± 5.9 at T1 at lower limbs, P = .04). The Visual Analogue Scale (VAS) for pain significantly worsened at upper limbs at T1 (mean values 0.84 ± 1.95 at T0 vs 1.78 ± 2.6 at T1, P = .03). All the other tests did not show significant differences between T0 and T1. In the subgroup who underwent rituximab (15/32 treated before T0, 3/32 patients treated between T0 and T1 with median interval of 1 year), no significant differences were observed between T0 and T1. Despite the quite long follow-up, statistical significance was not achieved either for the limited number of patients or for the lack of sensitive outcome measures. In our cohort, the significant worsening of the SMS and VAS after a median of 14 months can be considered as a reliable expression of the natural history of the disease, and suggest that these scales might represent possible outcome measures in anti-MAG antibody neuropathy.
Collapse
Affiliation(s)
- Marta Campagnolo
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Marta Ruiz
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Yuri M Falzone
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Ermani
- Department of Neurosciences, University of Padova, Padova, Italy
| | - Mariangela Bianco
- Neuromuscular and Neuroimmunology Service, Department of Medical Biotechnology and Translational Medicine, Milan University, IRCCS Humanitas Clinical and Research Institute, Milan, Italy
| | - Daniele Martinelli
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Cerri
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Angelo Quattrini
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Giancarlo Comi
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Università Vita e Salute San Raffaele, Milan, Italy
| | - Fabio Giannini
- Department of Medical and Surgical Sciences and Neurosciences, Siena University, Siena, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, Department of Medical Biotechnology and Translational Medicine, Milan University, IRCCS Humanitas Clinical and Research Institute, Milan, Italy
| | - Raffaella Fazio
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nilo Riva
- Department of Neurology, Institute of Experimental Neurology (INSPE), Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Briani
- Department of Neurosciences, University of Padova, Padova, Italy
| |
Collapse
|
25
|
Relevance of anti-HNK1 antibodies in the management of anti-MAG neuropathies. J Neurol 2019; 266:1973-1979. [DOI: 10.1007/s00415-019-09367-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 05/05/2019] [Accepted: 05/07/2019] [Indexed: 12/14/2022]
|
26
|
Falzone YM, Campagnolo M, Bianco M, Dacci P, Martinelli D, Ruiz M, Bocci S, Cerri F, Quattrini A, Comi G, Benedetti L, Giannini F, Lauria G, Nobile-Orazio E, Briani C, Fazio R, Riva N. Functioning and quality of life in patients with neuropathy associated with anti-MAG antibodies. J Neurol 2018; 265:2927-2933. [PMID: 30306264 PMCID: PMC6244677 DOI: 10.1007/s00415-018-9081-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/17/2018] [Accepted: 10/01/2018] [Indexed: 11/30/2022]
Abstract
Although anti-myelin-associated glycoprotein (MAG) antibody neuropathy is reported as a slowly progressive disease, it can lead to significant disability and impairment of health-related quality of life (HR-QoL) and social participation. The aim of this cross-sectional study was to evaluate the functioning and HR-QoL determinants in 67 patients with anti-MAG neuropathy in terms of the International Classification of Functioning, Disability, and Health (ICF). Evaluations included: Medical Research Council (MRC) sum score, Sensory Modality Sum score (SMS), Berg balance scale (BBS), Fatigue Severity Scale (FSS), Visual Analogue Scale (VAS) for pain, 9-Hole Peg Test (9-HPT), 6-min Walk Distance (6MWD), Impact on Participation and Autonomy (IPA) and the physical component score (PCS) and mental component score (MCS) of the short-form-36 health status scale (SF-36) HR-QoL measure. In the regression models, 6MWD was the most reliable predictor of PCS, explaining the 52% of its variance, while the strongest determinants of 6MWD were BBS and FSS, explaining the 41% of its variance. Consistently, VAS and BBS were good predictor of PCS, explaining together 54% of its variance. FSS was the most reliable determinant of MCS, explaining 25% of its variance. SMS and MRC were not QoL determinants. The results of our study suggest that 6MWD and FSS might be considered as potential meaningful outcome measures in future clinical trials. Furthermore, neurorehabilitation interventions aimed at improving balance and walking performance, fatigue management, and specific pain relief therapy should be considered to ameliorate participation in social life and HR-QoL in anti-MAG neuropathy patients.
Collapse
Affiliation(s)
- Yuri M Falzone
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marta Campagnolo
- Department of Neurosciences, Sciences University of Padova, Padova, Italy
| | - Mariangela Bianco
- Neuromuscular and Neuroimmunology Service, Department of Medical Biotechnology and Translational Medicine, IRCCS Humanitas Clinical and Research Institute, Milan University, Rozzano, Milan, Italy
| | - Patrizia Dacci
- Neurologia III, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Daniele Martinelli
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marta Ruiz
- Department of Neurosciences, Sciences University of Padova, Padova, Italy
| | - Silvia Bocci
- Department of Medical, Surgical and Neurological Sciences, Neurology and Clinical Neurophysiology Unit, University of Siena, Siena, Italy
| | - Federica Cerri
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Angelo Quattrini
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giancarlo Comi
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
- Università Vita e Salute San Raffaele, Milan, Italy
| | - Luana Benedetti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, IRCCS Policlinico San Martino, Genova, Italy
| | - Fabio Giannini
- Department of Medical, Surgical and Neurological Sciences, Neurology and Clinical Neurophysiology Unit, University of Siena, Siena, Italy
| | - Giuseppe Lauria
- Neurologia III, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, Department of Medical Biotechnology and Translational Medicine, IRCCS Humanitas Clinical and Research Institute, Milan University, Rozzano, Milan, Italy
| | - Chiara Briani
- Department of Neurosciences, Sciences University of Padova, Padova, Italy
| | - Raffaella Fazio
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nilo Riva
- Division of Neuroscience, Department of Neurology, Institute of Experimental Neurology (INSPE), IRCCS San Raffaele Scientific Institute, Milan, Italy.
| |
Collapse
|
27
|
An update on the diagnosis and management of the polyneuropathy of POEMS syndrome. J Neurol 2018; 266:258-267. [PMID: 30264176 PMCID: PMC6343023 DOI: 10.1007/s00415-018-9068-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 09/10/2018] [Accepted: 09/17/2018] [Indexed: 01/05/2023]
Abstract
POEMS syndrome is a rare, chronic, disabling paraneoplastic disorder characterized by peripheral neuropathy, organomegaly, endocrinopathy, monoclonal plasma cells disorder and skin changes. Diagnosis relies on the fulfillment of a set of clinical criteria of which polyneuropathy and a monoclonal plasma cell dyscrasia are early and essential features. Treatment may be either local or systemic and is aimed at the monoclonal plasma cell disorder. Our knowledge of the pathogenesis underlying the POEMS syndrome has advanced greatly over the past years, favoring an important progression in the recognition and management of this disorder. Here, we discuss the recent literature that has advanced our knowledge of the pathogenesis and clinical management of the polyneuropathy in POEMS syndrome.
Collapse
|
28
|
Abstract
PURPOSE OF REVIEW This article reviews the chronic demyelinating neuropathies, with a focus on the diagnosis and treatment of immune-mediated neuropathies and the features that can help differentiate immune-mediated neuropathies from other chronic demyelinating peripheral nerve conditions. RECENT FINDINGS Advances in clinical phenotyping and outcomes assessment have enabled neurologists to improve disease recognition, treatment, and disease monitoring. Our understanding of the immunopathogenesis of demyelinating neuropathies is evolving. Identification of new antibodies and recognition that node of Ranvier dysfunction may be an early pathogenic feature may herald further diagnostic and treatment advancements. SUMMARY The chronic demyelinating polyneuropathies are heterogeneous. The clinical and diagnostic features are sometimes overlapping, and the specific disorders are variable in pathogenesis, treatment, and prognosis. This heterogeneity underscores the importance of achieving diagnostic accuracy and implementing disease-specific treatment approaches.
Collapse
|
29
|
Svahn J, Petiot P, Antoine JC, Vial C, Delmont E, Viala K, Steck AJ, Magot A, Cauquil C, Zarea A, Echaniz-Laguna A, Iancu Ferfoglia R, Gueguen A, Magy L, Léger JM, Kuntzer T, Ferraud K, Lacour A, Camdessanché JP. Anti-MAG antibodies in 202 patients: clinicopathological and therapeutic features. J Neurol Neurosurg Psychiatry 2018; 89:499-505. [PMID: 29070644 DOI: 10.1136/jnnp-2017-316715] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the clinicopathological and therapeutic features of patients with low (≥1000 to <10 000 Bühlmann Titre Units) (BTU), medium (10 000-70 000) or high (≥70 000) anti-myelin-associated glycoprotein (anti-MAG) antibody titres. METHODS We retrospectively and prospectively analysed standardised report forms and medical records of 202 patients from 14 neuromuscular centres. RESULTS Mean age at onset and mean time between symptom onset to last follow-up were respectively 62.6 years (25-91.4) and 8.4 years (0.3-33.3). Anti-MAG antibody titres at diagnosis were low, medium or high in 11%, 51% and 38% of patients. Patients presented with monoclonal gammopathy of undetermined significance in 68% of cases. About 17% of patients presented with 'atypical' clinical phenotype independently of anti-MAG titres, including acute or chronic sensorimotor polyradiculoneuropathies (12.4%), and asymmetric or multifocal neuropathy (3%). At the most severe disease stage, 22.4% of patients were significantly disabled. Seventy-eight per cent of patients received immunotherapies. Transient clinical worsening was observed in 12% of patients treated with rituximab (11/92). Stabilisation after rituximab treatment during the 7-12-month follow-up period was observed in 29% of patients. Clinical response to rituximab during the 6-month and/or 7-12-month follow-up period was observed in 31.5% of patients and correlated with anti-MAG titre ≥10 000 BTU. CONCLUSION Our study highlights the extended clinical spectrum of patients with anti-MAG neuropathy, which appears unrelated to antibody titre. Besides, it may also suggest beneficial use of rituximab in the early phase of anti-MAG neuropathy.
Collapse
Affiliation(s)
- Juliette Svahn
- Electroneuromyography and Neuromuscular Department, University Hospital Lyon, Lyon, France
| | - Philippe Petiot
- Electroneuromyography and Neuromuscular Department, University Hospital Lyon, Lyon, France
| | | | - Christophe Vial
- Electroneuromyography and Neuromuscular Department, University Hospital Lyon, Lyon, France
| | - Emilien Delmont
- Department of Neurology, University Hospital Timone, Marseille, France
| | - Karine Viala
- Department of Neurophysiology and Neuropathology, University Hospital Pitié-Salpêtrière, Paris, France
| | - Andreas J Steck
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Armelle Magot
- Neuromuscular Reference Center, University Hospital Nantes, Nantes, France
| | - Cecile Cauquil
- Department of Neurology, University Hospital Bicêtre, Le Kremlin Bicêtre, France
| | - Aline Zarea
- Neuromuscular Competence Center, University Hospital Rouen, Rouen, France
| | | | - Ruxandra Iancu Ferfoglia
- Electroneuromyography and Neuromuscular Disorders Unit, University Hospital Geneva, Geneva, Switzerland
| | - Antoine Gueguen
- Department of Neurology, Fondation Ophtalmologique A. de Rothschild, Paris, France
| | - Laurent Magy
- Department of Neurology, University Hospital Limoges, Limoges, France
| | - Jean-Marc Léger
- Department of Neurology, University Hospital Pitié-Salpêtrière, Paris, France
| | - Thierry Kuntzer
- Department of Clinical Neurosciences, Nerve-Muscle Unit, Neurology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Karine Ferraud
- Department of Neurology, University Hospital Saint-Etienne, Saint-Etienne, France
| | - Arnaud Lacour
- Department of Neurology, University Hospital Saint-Etienne, Saint-Etienne, France
| | | | | |
Collapse
|
30
|
Dalakas MC. Advances in the diagnosis, immunopathogenesis and therapies of IgM-anti-MAG antibody-mediated neuropathies. Ther Adv Neurol Disord 2018; 11:1756285617746640. [PMID: 29403542 PMCID: PMC5791554 DOI: 10.1177/1756285617746640] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 11/16/2017] [Indexed: 11/17/2022] Open
Abstract
Polyneuropathy with immunoglobulin M (IgM) monoclonal gammopathy is the most common paraproteinemic neuropathy, comprising a clinicopathologically and immunologically distinct entity. The clinical spectrum spans from distal paresthesias and mild gait imbalance to more severe sensory ataxia, with falls and a varying degree of distal sensorimotor deficits. In approximately 75% of patients, the monoclonal IgM immunoreacts with myelin-associated glycoprotein (MAG) and sulfoglucuronyl glycosphingolipid (SGPG), or other peripheral nerve glycolipids that serve as antigens. These antibodies are considered pathogenic because IgM and complement are deposited on the myelin sheath, splitting the myelin lamellae, while adoptive transfer of patients’ IgM into susceptible host animals causes sensory ataxia and reproduces the human pathology. In spite of the apparently convincing pathogenicity of these antibodies, the response to immunotherapies remains suboptimal. Clorambuscil, cladibrine, cyclophospamide and intravenous immunoglobulin may help some patients but the benefits are minimal and transient. Open-label studies in >200 patients indicate that rituximab is helpful in 30–50% of these patients, even with long-term benefits, probably by suppressing IgM anti-MAG antibodies or inducing immunoregulatory T cells. Two controlled studies with rituximab did not however meet the primary endpoint, mostly because of the poor sensitivity of the scales used; they did however show statistical improvement in secondary endpoints and improved clinical functions in several patients. This review provides an overview of the clinical phenotypes and immunoreactivity of IgM to glycolipids or glycoproteins of peripheral nerve myelin, summarizes the progress on treatment with rituximab as a promising therapy, discusses the pitfalls of scales used, identifies possible biomarkers of response to therapy and highlights the promising new anti-B cell or target-specific immunotherapies.
Collapse
Affiliation(s)
- Marinos C Dalakas
- Neuroimmunology Unit, Department of Pathophysiology, National and Kapodistrian University of Athens Medical School, Athens, Greece
| |
Collapse
|
31
|
Mazzucchelli M, Frustaci AM, Deodato M, Cairoli R, Tedeschi A. Waldenstrom's Macroglobulinemia: An Update. Mediterr J Hematol Infect Dis 2018; 10:e2018004. [PMID: 29326801 PMCID: PMC5760071 DOI: 10.4084/mjhid.2018.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 11/13/2017] [Indexed: 12/19/2022] Open
Abstract
Waldenstrom Macroglobulinemia is a rare lymphoproliferative disorder with distinctive clinical features. Diagnostic and prognostic characterisation in WM significantly changed with the discovery of two molecular markers: MYD88 and CXCR4. Mutational status of these latter influences both clinical presentation and prognosis and demonstrated therapeutic implications. Treatment choice in Waldenstrom disease is strictly guided by patients age and characteristics, specific goals of therapy, the necessity for rapid disease control, the risk of treatment-related neuropathy, disease features, the risk of immunosuppression or secondary malignancies and potential for future autologous stem cell transplantation. The therapeutic landscape has expanded during the last years and the approval of ibrutinib, the first drug approved for Waldenstrom Macroglobulinemia, represents a significant step forward for a better management of the disease.
Collapse
Affiliation(s)
- Maddalena Mazzucchelli
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Anna Maria Frustaci
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Marina Deodato
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Roberto Cairoli
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Alessandra Tedeschi
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano
| |
Collapse
|
32
|
Distal Acquired Demyelinating Symmetric Neuropathy. Neuromuscul Disord 2018. [DOI: 10.1007/978-981-10-5361-0_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
33
|
Abstract
Waldenstrom Macroglobulinemia is a rare lymphoproliferative disorder with distinctive clinical features. Diagnostic and prognostic characterisation in WM significantly changed with the discovery of two molecular markers: MYD88 and CXCR4. Mutational status of these latter influences both clinical presentation and prognosis and demonstrated therapeutic implications. Treatment choice in Waldenstrom disease is strictly guided by patients age and characteristics, specific goals of therapy, the necessity for rapid disease control, the risk of treatment-related neuropathy, disease features, the risk of immunosuppression or secondary malignancies and potential for future autologous stem cell transplantation. The therapeutic landscape has expanded during the last years and the approval of ibrutinib, the first drug approved for Waldenstrom Macroglobulinemia, represents a significant step forward for a better management of the disease.
Collapse
|
34
|
Pruppers MH, Merkies IS, Lunn MP, Notermans NC, van den Bergh P, Blomkwist-Markens P, Cornblath D, D'Sa S, Faber C, Goedee S, Gorson K, Léger JM, Lewis R, Lunn M, Mazawey L, Merkies I, Nobile-Orazio E, Notermans N, Padua L, van der Pol L, Pruppers M, Querol L, Steck A, Willison H. 230th ENMC International Workshop:. Neuromuscul Disord 2017; 27:1065-1072. [DOI: 10.1016/j.nmd.2017.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Indexed: 12/30/2022]
|
35
|
Rajabally YA, Delmont E, Hiew FL, Aubé-Nathier AC, Grapperon AM, Cassereau J, Attarian S. Prevalence, correlates and impact of pain and cramps in anti-MAG neuropathy: a multicentre European study. Eur J Neurol 2017; 25:135-141. [DOI: 10.1111/ene.13459] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 09/07/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Y. A. Rajabally
- School of Life and Health Sciences, Aston Brain Centre; Aston University; Birmingham UK
- Regional Neuromuscular Clinic, Queen Elizabeth Hospital; University Hospitals of Birmingham; Birmingham UK
| | - E. Delmont
- Reference Centre for Neuromuscular Diseases and ALS; Centre Hospitalier Universitaire La Timone; Marseille France
| | - F. L. Hiew
- Regional Neuromuscular Clinic, Queen Elizabeth Hospital; University Hospitals of Birmingham; Birmingham UK
| | - A.-C. Aubé-Nathier
- Centre de Référence Maladies Neuromusculaires de l'Enfant et de l'Adulte Nantes-Angers; Centre Hospitalier Universitaire d'Angers; Angers France
| | - A.-M. Grapperon
- Reference Centre for Neuromuscular Diseases and ALS; Centre Hospitalier Universitaire La Timone; Marseille France
| | - J. Cassereau
- Centre de Référence Maladies Neuromusculaires de l'Enfant et de l'Adulte Nantes-Angers; Centre Hospitalier Universitaire d'Angers; Angers France
| | - S. Attarian
- Reference Centre for Neuromuscular Diseases and ALS; Centre Hospitalier Universitaire La Timone; Marseille France
| |
Collapse
|
36
|
Nobile-Orazio E, Bianco M, Nozza A. Advances in the Treatment of Paraproteinemic Neuropathy. Curr Treat Options Neurol 2017; 19:43. [DOI: 10.1007/s11940-017-0479-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
37
|
Nobile-Orazio E, Gallia F, Terenghi F, Bianco M. Comparing treatment options for chronic inflammatory neuropathies and choosing the right treatment plan. Expert Rev Neurother 2017; 17:755-765. [DOI: 10.1080/14737175.2017.1340832] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Eduardo Nobile-Orazio
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), University of Milan, Milan, Italy
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| | - Francesca Gallia
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| | - Fabrizia Terenghi
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| | - Mariangela Bianco
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Clinical Institute, Milan, Italy
| |
Collapse
|
38
|
Gazzola S, Delmont E, Franques J, Boucraut J, Salort-Campana E, Verschueren A, Sagui E, Hubert AM, Pouget J, Attarian S. Predictive factors of efficacy of rituximab in patients with anti-MAG neuropathy. J Neurol Sci 2017; 377:144-148. [DOI: 10.1016/j.jns.2017.04.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 02/21/2017] [Accepted: 04/10/2017] [Indexed: 01/01/2023]
|
39
|
Chaudhry HM, Mauermann ML, Rajkumar SV. Monoclonal Gammopathy-Associated Peripheral Neuropathy: Diagnosis and Management. Mayo Clin Proc 2017; 92:838-850. [PMID: 28473042 PMCID: PMC5573223 DOI: 10.1016/j.mayocp.2017.02.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 01/31/2017] [Accepted: 02/03/2017] [Indexed: 11/25/2022]
Abstract
Monoclonal gammopathies comprise a spectrum of clonal plasma cell disorders that include monoclonal gammopathy of undetermined significance, multiple myeloma, and Waldenström macroglobulinemia. In this review, we outline the epidemiology, etiology, classification, diagnosis, and treatment of monoclonal gammopathy-associated peripheral neuropathy. Monoclonal gammopathy of undetermined significance is relatively common in the general population, with a prevalence of 3% to 4% among individuals older than age 50 years. Therefore, the presence of M protein in a patient with neuropathy does not automatically indicate a causal relationship. Monoclonal gammopathy-associated peripheral neuropathy is often a difficult diagnosis with limited treatment options. Studies addressing the optimal approach to diagnosis and management of this entity are limited. In addition to a review of the literature, we present a diagnostic approach to patients with monoclonal gammopathy-associated peripheral neuropathy and discuss available data and options for treatment.
Collapse
|
40
|
Delmont E, Hiew FL, Cassereau J, Aubé-Nathier AC, Grapperon AM, Attarian S, Rajabally YA. Determinants of health-related quality of life in anti-MAG neuropathy: a cross-sectional multicentre European study. J Peripher Nerv Syst 2017; 22:27-33. [DOI: 10.1111/jns.12197] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/16/2016] [Accepted: 11/17/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Emilien Delmont
- Referral Centre for Neuromuscular Diseases and ALS; University Hospital La Timone; Marseille France
- Aix-Marseille University; CNR2M, CNRS UMR 7286, Medicine Faculty; Marseille France
| | - Fu Liong Hiew
- Regional Neuromuscular Clinic, Queen Elizabeth Hospital; University Hospitals of Birmingham; Birmingham UK
| | - Julien Cassereau
- Centre de Référence Maladies Neuromusculaires de l'Enfant et de l'Adulte Nantes-Angers; Centre Hospitalier Universitaire d'Angers; Angers France
| | - Anne-Catherine Aubé-Nathier
- Centre de Référence Maladies Neuromusculaires de l'Enfant et de l'Adulte Nantes-Angers; Centre Hospitalier Universitaire d'Angers; Angers France
| | - Aude-Marie Grapperon
- Referral Centre for Neuromuscular Diseases and ALS; University Hospital La Timone; Marseille France
| | - Shahram Attarian
- Referral Centre for Neuromuscular Diseases and ALS; University Hospital La Timone; Marseille France
- Inserm UMR S 910 Medical Genetics and Functional Genomics; Aix Marseille University; Marseille France
| | - Yusuf A. Rajabally
- Regional Neuromuscular Clinic, Queen Elizabeth Hospital; University Hospitals of Birmingham; Birmingham UK
- School of Life and Health Sciences, Aston Brain Centre; Aston University; Birmingham UK
| |
Collapse
|
41
|
D'Sa S, Kersten MJ, Castillo JJ, Dimopoulos M, Kastritis E, Laane E, Leblond V, Merlini G, Treon SP, Vos JM, Lunn MP. Investigation and management of IgM and Waldenström-associated peripheral neuropathies: recommendations from the IWWM-8 consensus panel. Br J Haematol 2017; 176:728-742. [PMID: 28198999 DOI: 10.1111/bjh.14492] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Paraproteinaemic neuropathies are a heterogeneous group of disorders most frequently associated with IgM monoclonal gammopathies including Waldenström macroglobulinaemia (WM). Their consequences are significant for affected patients, and their management challenging for their physicians. The variability in clinical presentation and time course hamper classification and management. The indications for invasive investigations such as cerebrospinal fluid analysis, nerve conduction tests and sensory nerve biopsies are unclear, and the optimum way to measure clinical response to treatment unknown. When to intervene and and how to treat, also present challenges to physicians. As part of its latest deliberations at the International Workshops on WM (IWWM) in London, UK (August 2014), the IWWM8 panel have proposed a consensus approach to the diagnosis and management of peripheral neuropathies associated with IgM monoclonal gammopathies, including WM. Importantly, a consensus regarding the use of clinical outcome measures and recommended models of care for this group of patients is discussed, as well as appropriate treatment interventions.
Collapse
Affiliation(s)
- Shirley D'Sa
- Waldenström Clinic, Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Marie José Kersten
- Department of Haematology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Meletios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Edward Laane
- Department of Haematology, North Estonia Medical Centre, Tallinn, Estonia
| | - Véronique Leblond
- AP-HP Hôpital Pitié Salpêtrière, UPMC Univ. Paris 6 GRC-11, Grechy, Paris, France
| | - Giampaolo Merlini
- Centre for Research and Treatment of Systemic Amyloidosis, University of Pavia, Pavia, Italy
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Josephine M Vos
- Department of Haematology, Academic Medical Centre, Amsterdam, the Netherlands.,Cancer Centre, Sint Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | - Michael P Lunn
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| |
Collapse
|
42
|
Are electrophysiological features related to disability in patients with anti-MAG neuropathy? Neurophysiol Clin 2017; 47:75-81. [DOI: 10.1016/j.neucli.2017.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 01/04/2017] [Indexed: 12/23/2022] Open
|
43
|
Lunn MPT, Nobile‐Orazio E. Immunotherapy for IgM anti-myelin-associated glycoprotein paraprotein-associated peripheral neuropathies. Cochrane Database Syst Rev 2016; 10:CD002827. [PMID: 27701752 PMCID: PMC6457998 DOI: 10.1002/14651858.cd002827.pub4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Serum monoclonal anti-myelin-associated glycoprotein (anti-MAG) antibodies may be pathogenic in some people with immunoglobulin M (IgM) paraprotein and demyelinating neuropathy. Immunotherapies aimed at reducing the level of these antibodies might be expected to be beneficial. This is an update of a review first published in 2003 and previously updated in 2006 and 2012. OBJECTIVES To assess the effects of immunotherapy for IgM anti-MAG paraprotein-associated demyelinating peripheral neuropathy. SEARCH METHODS On 1 February 2016 we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase for randomised controlled trials (RCTs). We also checked trials registers and bibliographies, and contacted authors and experts in the field. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs involving participants of any age treated with any type of immunotherapy for anti-MAG antibody-associated demyelinating peripheral neuropathy with monoclonal gammopathy of undetermined significance and of any severity.Our primary outcome measures were numbers of participants improved in disability assessed with either or both of the Neuropathy Impairment Scale (NIS) or the modified Rankin Scale (mRS) at six months after randomisation. Secondary outcome measures were: mean improvement in disability, assessed with either the NIS or the mRS, 12 months after randomisation; change in impairment as measured by improvement in the 10-metre walk time, change in a validated linear disability measure such as the Rasch-built Overall Disability Scale (R-ODS) at six and 12 months after randomisation, change in subjective clinical scores and electrophysiological parameters at six and 12 months after randomisation; change in serum IgM paraprotein concentration or anti-MAG antibody titre at six months after randomisation; and adverse effects of treatments. DATA COLLECTION AND ANALYSIS We followed standard methodological procedures expected by Cochrane. MAIN RESULTS We identified eight eligible trials (236 participants), which tested intravenous immunoglobulin (IVIg), interferon alfa-2a, plasma exchange, cyclophosphamide and steroids, and rituximab. Two trials of IVIg (22 and 11 participants, including 20 with antibodies against MAG), had comparable interventions and outcomes, but both were short-term trials. We also included two trials of rituximab with comparable interventions and outcomes.There were very few clinical or statistically significant benefits of the treatments used on the outcomes predefined for this review, but not all the predefined outcomes were used in every included trial and more responsive outcomes are being developed. A well-performed trial of IVIg, which was at low risk of bias, showed a statistical benefit in terms of improvement in mRS at two weeks and 10-metre walk time at four weeks, but these short-term outcomes are of questionable clinical significance. Cyclophosphamide failed to show any benefit in the single trial's primary outcome, and showed a barely significant benefit in the primary outcome specified here, but some toxic adverse events were identified.Two trials of rituximab (80 participants) have been published, one of which (26 participants) was at high risk of bias. In the meta-analysis, although the data are of low quality, rituximab is beneficial in improving disability scales (Inflammatory Neuropathy Cause and Treatment (INCAT) improved at eight to 12 months (risk ratio (RR) 3.51, 95% confidence interval (CI) 1.30 to 9.45; 73 participants)) and significantly more participants improve in the global impression of change score (RR 1.86, 95% CI 1.27 to 2.71; 70 participants). Other measures did not improve significantly, but wide CIs do not preclude some effect. Reported adverse effects of rituximab were few, and mostly minor.There were few serious adverse events in the other trials. AUTHORS' CONCLUSIONS There is inadequate reliable evidence from trials of immunotherapies in anti-MAG paraproteinaemic neuropathy to form an evidence base supporting any particular immunotherapy treatment. IVIg has a statistically but probably not clinically significant benefit in the short term. The meta-analysis of two trials of rituximab provides, however, low-quality evidence of a benefit from this agent. The conclusions of this meta-analysis await confirmation, as one of the two included studies is of very low quality. We require large well-designed randomised trials of at least 12 months' duration to assess existing or novel therapies, preferably employing unified, consistent, well-designed, responsive, and valid outcome measures.
Collapse
Affiliation(s)
- Michael PT Lunn
- National Hospital for Neurology and NeurosurgeryDepartment of Neurology and MRC Centre for Neuromuscular DiseasesQueen SquareLondonUKWC1N 3BG
| | - Eduardo Nobile‐Orazio
- Milan UniversityIRCCS Humanitas Clinical Institute, Neurology 2Istituto Clinico HumanitasVia Manzoni 56, RozzanoMilanItaly20089
| | | |
Collapse
|
44
|
Vallat JM, Magy L, Ciron J, Corcia P, Le Masson G, Mathis S. Therapeutic options and management of polyneuropathy associated with anti-MAG antibodies. Expert Rev Neurother 2016; 16:1111-9. [DOI: 10.1080/14737175.2016.1198257] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
45
|
Galassi G, Tondelli M, Ariatti A, Benuzzi F, Nichelli P, Valzania F. Long-term disability and prognostic factors in polyneuropathy associated with anti-myelin-associated glycoprotein (MAG) antibodies. Int J Neurosci 2016; 127:439-447. [PMID: 27188752 DOI: 10.1080/00207454.2016.1191013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM OF THE STUDY Neuropathy associated with IgM monoclonal gammopathy (MGUS) represents distinctive clinical syndrome, characterized by male predominance, late age of onset, slow progression, predominantly sensory symptoms, deep sensory loss, ataxia, minor motor impairment. More than 50% of patients with neuropathy-associated MGUS possess antibodies against myelin-associated glycoprotein (MAG). Purpose of our study was to assess effects on disease progression of demographic, clinical and neurophysiological variables in our large cohort of patients. MATERIALS AND METHODS Forty-three Caucasians patients were followed every eight months for median duration time of 93 months. Extremity strength was assessed with Medical Research Council (MRC) Scale, disability with overall disability status scale (ODSS), modified Rankin Scale and sensory function with Inflammatory Neuropathy Cause and Treatment (INCAT) sensory scale (ISS). Statistical analyses were conducted with parametric or non-parametric measures as appropriate. Survival analysis was used to test predictive value of clinical, demographical and neurophysiological variables. Variance analysis was conducted to explain difference on MRC between patients and groups at different time from onset. RESULTS Results showed that demyelinating pattern, older age and absence of treatment were significant risk factors for disability worsening. No other factors emerged as predictors including gender, ataxia and tremor at baseline, level of anti-MAG and IgM protein concentration in serum. Despite worsening of all outcome measures between first and last visit, quality of life (HRQol) judged by patients did not vary significantly. CONCLUSIONS Our study provides evidence that electrophysiologic pattern, age of onset and absence of treatment are strong predictor of prognosis in anti-MAG polyneuropathy.
Collapse
Affiliation(s)
- Giuliana Galassi
- a Department of Biomedical, Metabolic and Neural Science , University of Modena & Reggio Emilia , Modena , Italy
| | - Manuela Tondelli
- a Department of Biomedical, Metabolic and Neural Science , University of Modena & Reggio Emilia , Modena , Italy
| | - Alessandra Ariatti
- a Department of Biomedical, Metabolic and Neural Science , University of Modena & Reggio Emilia , Modena , Italy
| | - Francesca Benuzzi
- a Department of Biomedical, Metabolic and Neural Science , University of Modena & Reggio Emilia , Modena , Italy
| | - Paolo Nichelli
- a Department of Biomedical, Metabolic and Neural Science , University of Modena & Reggio Emilia , Modena , Italy
| | - Franco Valzania
- a Department of Biomedical, Metabolic and Neural Science , University of Modena & Reggio Emilia , Modena , Italy
| |
Collapse
|
46
|
Živković S. Intravenous immunoglobulin in the treatment of neurologic disorders. Acta Neurol Scand 2016; 133:84-96. [PMID: 25997034 DOI: 10.1111/ane.12444] [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] [Accepted: 04/05/2015] [Indexed: 12/17/2022]
Abstract
Intravenous immunoglobulins (IVIGs) are often used in the treatment of autoimmune disorders and immunodeficiencies, and it has been estimated that neurologic indications can account for up to 43% of IVIG used in clinical practice. In neurologic clinical practice, IVIG is used for acute therapy of newly diagnosed autoimmune disorders or exacerbations of pre-existing conditions, or as long-term maintenance treatment for chronic disorders. IVIG exerts its effects on humoral and cell-based immunity through multiple pathways, without a single dominant mechanism. Clinical use of IVIG has been supported by guidelines from American Academy of Neurology and European Federation of Neurologic Societies. IVIG is generally recommended for the treatment of Guillain-Barre syndrome and chronic inflammatory demyelinating polyneuropathy in adults, multifocal motor neuropathy and myasthenia gravis, and should be considered as a treatment option for dermatomyositis in adults and Lambert-Eaton myasthenic syndrome. Additional potential indications include stiff person syndrome, multiple sclerosis during pregnancy or while breastfeeding, refractory autoimmune epilepsy, and paraneoplastic disorders. Clinical use of IVIG is mostly safe but few adverse effects may still occur with potentially severe complications, including aseptic meningitis and thromboembolism. In addition to intravenous route (IVIG), subcutaneous immunoglobulins have been used as an alternative treatment option, especially in patients with limited intravenous access. Treatment with IVIG is effective in various autoimmune diseases, but its broader use is constrained by limited supply. This review evaluates the use of immunoglobulins in treatment of neurologic diseases.
Collapse
Affiliation(s)
- S. Živković
- Department of Neurology; University of Pittsburgh Medical Center; Pittsburgh PA USA
| |
Collapse
|
47
|
Rison RA, Beydoun SR. Paraproteinemic neuropathy: a practical review. BMC Neurol 2016; 16:13. [PMID: 26821540 PMCID: PMC4731930 DOI: 10.1186/s12883-016-0532-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 01/16/2016] [Indexed: 12/14/2022] Open
Abstract
The term paraproteinemic neuropathy describes a heterogeneous set of neuropathies characterized by the presence of homogeneous immunoglobulin in the serum. An abnormal clonal proliferation of B-lymphocytes or plasma cells, which may or may not occur in the context of a hematologic malignancy, produces the immunoglobulins in excess. If malignancy is identified, treatment should be targeted to the neoplasm. Most cases, however, occur as monoclonal gammopathy of undetermined significance. Few prospective, randomized, placebo-controlled trials are available to inform the management of paraproteinemic neuropathies. Clinical experience combined with data from smaller, uncontrolled studies provide a basis for recommendations, which depend on the specific clinical setting in which the paraprotein occurs. In this review, we provide a clinically practical approach to diagnosis and management of such patients.
Collapse
Affiliation(s)
- Richard A Rison
- University of Southern California, Keck School of Medicine, Los Angeles County Medical Center, Medical Director PIH Health-Whittier Stroke Program, Neurology Consultants Medical Group, 12401 Washington Blvd., Whittier, CA, 90602, USA.
| | - Said R Beydoun
- University of Southern California, Keck School of Medicine, Los Angeles County Medical Center, 1520 San Pablo Street Suite 3000, Los Angeles, CA, 90033, USA.
| |
Collapse
|
48
|
Mathey EK, Park SB, Hughes RAC, Pollard JD, Armati PJ, Barnett MH, Taylor BV, Dyck PJB, Kiernan MC, Lin CSY. Chronic inflammatory demyelinating polyradiculoneuropathy: from pathology to phenotype. J Neurol Neurosurg Psychiatry 2015; 86:973-85. [PMID: 25677463 PMCID: PMC4552934 DOI: 10.1136/jnnp-2014-309697] [Citation(s) in RCA: 259] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/09/2014] [Accepted: 12/11/2014] [Indexed: 11/04/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an inflammatory neuropathy, classically characterised by a slowly progressive onset and symmetrical, sensorimotor involvement. However, there are many phenotypic variants, suggesting that CIDP may not be a discrete disease entity but rather a spectrum of related conditions. While the abiding theory of CIDP pathogenesis is that cell-mediated and humoral mechanisms act together in an aberrant immune response to cause damage to peripheral nerves, the relative contributions of T cell and autoantibody responses remain largely undefined. In animal models of spontaneous inflammatory neuropathy, T cell responses to defined myelin antigens are responsible. In other human inflammatory neuropathies, there is evidence of antibody responses to Schwann cell, compact myelin or nodal antigens. In this review, the roles of the cellular and humoral immune systems in the pathogenesis of CIDP will be discussed. In time, it is anticipated that delineation of clinical phenotypes and the underlying disease mechanisms might help guide diagnostic and individualised treatment strategies for CIDP.
Collapse
Affiliation(s)
- Emily K Mathey
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Susanna B Park
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia Neuroscience Research Australia & Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - Richard A C Hughes
- MRC Centre for Neuromuscular Diseases, Institute of Neurology, University College London, London, UK
| | - John D Pollard
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Patricia J Armati
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Michael H Barnett
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Bruce V Taylor
- Menzies Research Institute, University of Tasmania, Sydney, New South Wales, Australia
| | - P James B Dyck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew C Kiernan
- Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Cindy S-Y Lin
- Faculty of Medicine, Department of Physiology, Translational Neuroscience Facility, School of Medical Sciences, University of New South Wales, Randwick, New South Wales, Australia
| |
Collapse
|
49
|
Heterogeneity of Polyneuropathy Associated with Anti-MAG Antibodies. J Immunol Res 2015; 2015:450391. [PMID: 26065001 PMCID: PMC4438150 DOI: 10.1155/2015/450391] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 04/07/2015] [Indexed: 11/17/2022] Open
Abstract
Polyneuropathy associated with IgM monoclonal gammopathy and anti-myelin associated glycoprotein (MAG) antibodies is an immune-mediated demyelinating neuropathy. The pathophysiology of this condition is likely to involve anti-MAG antibody deposition on myelin sheaths of the peripheral nerves and it is supposed to be distinct from chronic inflammatory demyelinating neuropathy (CIDP), another immune-mediated demyelinating peripheral neuropathy. In this series, we have retrospectively reviewed clinical and laboratory findings from 60 patients with polyneuropathy, IgM gammopathy, and anti-MAG antibodies. We found that the clinical picture in these patients is highly variable suggesting a direct link between the monoclonal gammopathy and the neuropathy. Conversely, one-third of patients had a CIDP-like phenotype on electrodiagnostic testing and this was correlated with a low titer of anti-MAG antibodies and the absence of widening of myelin lamellae. Our data suggest that polyneuropathy associated with anti-MAG antibodies is less homogeneous than previously said and that the pathophysiology of the condition is likely to be heterogeneous as well with the self-antigen being MAG in most of the patients but possibly being another component of myelin in the others.
Collapse
|
50
|
Hamada Y, Hirano M, Kuwahara M, Samukawa M, Takada K, Morise J, Yabuno K, Oka S, Kusunoki S. Binding specificity of anti-HNK-1 IgM M-protein in anti-MAG neuropathy: Possible clinical relevance. Neurosci Res 2015; 91:63-8. [DOI: 10.1016/j.neures.2014.09.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 09/24/2014] [Accepted: 09/25/2014] [Indexed: 11/17/2022]
|