Immunomodulatory treatment in postural tachycardia syndrome: A case series

BACKGROUND AND PURPOSE

Postural tachycardia syndrome (POTS) is a form of autonomic dysfunction characterized by symptoms of orthostatic intolerance, often accompanied by sudomotor dysfunction and gastrointestinal dysmotility. Recently, evidence has accumulated that in a subset of patients, the pathogenesis of dysautonomia may be immune-mediated. The aim of the current report was to evaluate the use of intravenous immunoglobulin (IVIG) treatment in patients with progressive and/or refractory immune-mediated POTS.

METHODS

We retroactively assessed the effect and tolerance of monthly administered IVIG in six patients using autonomic function testing, standardized symptom questionnaires, and patients' symptom diaries both before and 6 months into IVIG treatment. Objective outcome measures included heart rate increase after 10 min of head-up tilt as well as duration and anhidrotic area in a thermoregulatory sweat test. Subjective outcome measures were patient reports and symptom ratings from the symptom questionnaire.

RESULTS

All patients responded to immunomodulatory treatment, regardless of disease duration. After 6 months of IVIG, symptom severity was reduced by nearly 40%. Autonomic function testing showed improved cardiovascular functioning by 50% and a reduction of anhidrotic areas by one third. Overall, tolerance of IVIG treatment was poor, but could be improved by a reduction in infusion rate, premedication with steroids, and additional intravenous hydration.

CONCLUSIONS

Using subjective but also standardized objective measures, the case series describes promising effects of IVIG treatment in POTS patients with immune-mediated dysautonomia. By reducing the infusion rate, pretreatment with steroids, and intravenous hydration, tolerance could be improved, and no patient had to discontinue the treatment.

Differences between proximal and distal portions of the male rabbit posterior urethra in the physiological role of muscarinic cholinergic receptors

1. The aim of the present study was to elucidate functional differences between embryologically different portions of the posterior urethra of male rabbits in response to muscarinic acetylcholine receptor (mAChR) stimulation using in vitro isometric tension experiments and radioligand binding studies. 2. In the in vitro isometric tension experiments, carbachol, produced a dose-dependent contraction of the proximal portion under the resting state, but did not change the basal tone of the distal portion. Contraction of the proximal portion by 10(-5) M noradrenaline (NA) was dose-dependently enhanced by carbachol either in the presence or absence of NG-nitro-L-arginine (NOARG). In contrast, carbachol induced relaxation of the distal portion contracted by 10(-5) M NA, which was reversed to dose-dependent contraction in the presence of NOARG. 3. Both portions of the urethra had a similar number of [3H]-quinuclidinyl benzilate ([3H]-QNB) binding sites (195.3+/-74.1 fmols mg(-1) protein for the proximal portion and 146.5+/-8.5 fmols mg(-1) protein for the distal portion) with similar affinities (115.0+/-45.4 pM for the proximal portion and 79.9+ 2.9 pM for the distal portion). 4. The concentration-response curves to carbachol in both portions were shifted to the right in a parallel manner in the presence of pirenzepine (an M1 antagonist), 11-[[2-[(diethylamino)methyl]-1-piperidinyl] acetyl]-5, 11-dihydro-6H-pyrido-2,3-b)-(1,4)-benzodiazepin-6-one (AFDX-116, an M2 antagonist) and 4-diphenyl-acetoxy-N-methyl-piperidine (4-DAMP, an M1/M3 antagonist). The pA2 values for pirenzepine, AFDX-116 and 4-DAMP were 7.5+/-0.1, 7.2+/-0.02 and 9.3+/-0.1 respectively for the contraction of the proximal portion, and 7.2+/-0.1, 7.1+/-0.2 and 9.1+/-0.2, respectively for the relaxation of the distal portion. 5. In conclusion mAChR subtypes distribute in a similar fashion throughout the length of the male rabbit posterior urethra with the discrepant responses to carbachol attributable to the differential involvement of the NO pathway in mAChR-generated reactions.