POEMS syndrome: Update on diagnosis, risk-stratification, and management

DISEASE OVERVIEW

POEMS syndrome is a life-threatening condition due to an underlying plasma cell neoplasm. The major criteria for the syndrome are polyradiculoneuropathy, clonal plasma cell disorder, sclerotic bone lesions, elevated vascular endothelial growth factor, and the presence of Castleman disease. Minor features include organomegaly, endocrinopathy, characteristic skin changes, papilledema, extravascular volume overload, and thrombocytosis.

DIAGNOSIS

The diagnosis of POEMS syndrome is made with three of the major criteria, two of which must include polyradiculoneuropathy and clonal plasma cell disorder, and at least one of the minor criteria.

RISK STRATIFICATION

Because the pathogenesis of the syndrome is not well understood, risk stratification is limited to clinical phenotype rather than specific molecular markers. Risk factors include low serum albumin, age, pleural effusion, pulmonary hypertension, and reduced estimated glomerular filtration rate.

RISK-ADAPTED THERAPY

For those patients with a dominant plasmacytoma, first-line therapy is irradiation. Patients with diffuse sclerotic lesions or disseminated bone marrow involvement should receive systemic therapy. Corticosteroids are temporizing, but alkylators and lenalidomide are the mainstays of treatment, the former either in the form of low-dose conventional therapy or as high-dose conditioning for stem cell transplantation. Thalidomide and bortezomib also have activity, but their benefit needs to be weighed against their risk of exacerbating the peripheral neuropathy. Daratumumab combinations also appear promising based on case series. Prompt recognition and institution of both supportive care measures and therapy directed against the plasma cell result in the best outcomes.

Varicella zoster virus associated-polyradiculoneuritis in an elderly woman: A new subtype of varicella zoster virus neuropathy

An 82-year-old Japanese woman without underlying disease was admitted to our hospital 3 days after she noticed lower-limb weakness. At presentation, she had lower-leg motor paralysis with mild upper-limb paresis and left Ramsay Hunt syndrome. Cerebrospinal fluid (CSF) findings revealed moderate pleocytosis. A polymerase chain reaction for varicella zoster virus (VZV) DNA in CSF was positive. MRI using 3D Nerve-VIEW (Philips) and contrast T₁ images showed high-intensity lesions on the L2-5 and S1-2 spinal roots. A new subtype of VZV-associated polyradiculoneuritis was diagnosed in this patient. We provide the case details and compare three similar reported cases.

Diffuse large B-cell lymphoma involving peripheral nervous system with IgM antibodies against GM1 and GD1b: A case report

RATIONALE

The occurrence of peripheral neuropathy associated with non-Hodgkin's lymphoma (NHL) is uncommon. And autoimmunity may play an important role. We report a case of the patient with NHL, has sensorimotor demyelinating polyneuropathy.

PATIENT CONCERNS

The patient presented with a 1-month history of progressive numbness at the distal extremities and motor weakness of the lower limbs. Meanwhile, patient also endorsed a painful lump on her right cheek. And then the enlarged cervical and supra clavicular lymph nodes were observed on admission. Biopsy of the lymph nodes showed NHL. Serum IgM antibodies against GM1 and GD1b were also positive.

DIAGNOSIS

Biopsy of the lymph nodes showed NHL. Serum IgM antibodies against GM1 and GD1b were also positive. Thus, the patience was diagnosed with lymphoma and sensorimotor polyneuropathy.

INTERVENTIONS

Patient refused the further treatment.

OUTCOMES

After 11-month follow-up, the weakness of bilateral lower limbs worsens.

LESSONS

We have presented a case of NHL involving peripheral polyneuropathy with IgM antibodies against GM1 and GD1b. Patients may initially present with peripheral nerve complications or develop them during the course of lymphoma, even when in remission. This could complicate the diagnosis of peripheral polyneuropathy secondary to NHL.

Wernicke encephalopathy concurrent with polyradiculoneuropathy in a young man after bariatric surgery: A case report

RATIONALE

Bariatric surgery is the recommended treatment for morbid obesity because of its rapid and sustained body weight loss effect. Nutrient deficiency-related neurological complications after bariatric surgery are often disabling. Thus, early recognition of these complications is important. Neurological complications involving the central and peripheral nerve system after bariatric surgery were reported. However, the report on the clinical course of the concurrent involvement of central and peripheral nervous system is limited. We present a rare case of a patient who developed Wernicke encephalopathy concurrent with polyradiculoneuropathy after receiving bariatric surgery.

PATIENT CONCERNS

A 22-year-old man with a history of morbid obesity presented progressive bilateral lower limbs weakness, blurred vision, and gait disturbance 2 months after receiving laparoscopic sleeve gastrectomy. Bilateral lower limb numbness and cognition impairment were also noted.

DIAGNOSIS

Brain magnetic resonance imaging and electrophysiologic studies confirmed the diagnosis of Wernicke encephalopathy concurrent with acute polyradiculoneuropathy.

INTERVENTIONS

Vitamin B and folic acid were given since admission. He also received regular intensive rehabilitation program.

OUTCOMES

The subject's cognitive impairment and diplopia improved 1 week after admission under medical treatments, yet lower limb weakness and gait disturbance were still noted. After a month of intensive inpatient rehabilitation, he was able to ambulate with a walker for 30 munder supervision.

LESSONS

Nutrient deficiency-related neurological complications after bariatric surgery are often disabling and even fatal. Prevention of neurological complications can be improved through close postsurgical follow-up of the nutritional status. Recognizing the signs and symptoms and evaluating the medical history are critical to the early diagnosis and treatment of this potentially serious yet treatable condition.

DEVELOPMENT OF GANGLIONOPATHY AND TABETIC VISCERAL CRISES ON THE BACKGROUND OF POLYRADICULONEUROPATHY ASSOCIATED WITH MONOCLONAL GAMMOPATHY (CASE REPORT)

The article presents an analysis of the clinical occurrence of development of chronic polyradiculoneuropathy associated with monoclonal IgG/k (kappa) gammopathy of the undetermined significance. The peculiarity of this occurrence is the uniqueness of the development of the symptoms which are characteristic of tabes dorsalis in this pathology with episodic severe visceral crises and also with ganglionopathy. The example describes the clinical polymorphism of the course of visceral crises, the problems of their diagnosis and as a consequence of inadequate treatment with the development of severe social maladaptation. The importance of timely diagnosis and treatment of such conditions is discussed.

Acute lower motor neuron tetraparesis

Flaccid nonambulatory tetraparesis or tetraplegia is an infrequent neurologic presentation; it is characteristic of neuromuscular disease (lower motor neuron [LMN] disease) rather than spinal cord disease. Paresis beginning in the pelvic limbs and progressing to the thoracic limbs resulting in flaccid tetraparesis or tetraplegia within 24 to 72 hours is a common presentation of peripheral nerve or neuromuscular junction disease. Complete body flaccidity develops with severe decrease or complete loss of spinal reflexes in pelvic and thoracic limbs. Animals with acute generalized LMN tetraparesis commonly show severe motor dysfunction in all limbs and severe generalized weakness in all muscles.

Guillain-Barré in a 10-month-old: diagnostic challenges in a pediatric emergency

A 10-month-old male infant presented to the emergency department (ED) with a chief complaint of weakness, decreased mobility, and regression of motor milestones over a period of 6 days. Significant medical history included a Roseola infection 5 weeks before ED presentation. The patient's pediatrician and chiropractor had both previously diagnosed the patient with strains and sprains. After progression of symptoms, the patient presented to the ED and was discharged home to follow up as an outpatient. The patient subsequently returned to the ED and was admitted to neurology with concern for Guillain-Barré syndrome, which was later confirmed after inpatient workup. The patient was successfully treated and released. Guillain-Barré represents a spectrum of acute immune mediated polyneuropathies. There are several variant forms provoked by infection that precedes the onset of symptoms. Diagnosis and management of Guillain-Barré in the ED will be reviewed, along with the importance of early pediatric intensive care involvement for children presenting with signs of flaccid quadriparesis; rapidly progressive weakness; impending respiratory failure; bulbar palsy; and, most importantly, autonomic cardiovascular instability. Guillain-Barré is rare in children younger than 2 years; however, it must be considered in the differential diagnosis of any patient who presents with progressive weakness and history of a recent infection. It is important to recognize the variety and severity of neurologic symptoms associated with Guillain-Barré across a spectrum, especially with the diagnostic difficulties associated with the pediatric population.

Acute polyradiculoneuritis syndrome: clinical observations and differential diagnosis

Guillain-Barré syndrome (GBS) and neuroborreliosis may clinically manifest with symptoms related to acute polyradiculoneuritis. The aim and purpose of this study was analysis of clinical picture in patients with acute polyradiculoneuritis and their differential diagnosis into patients with GBS or meningoradiculoneuritis within the framework of neuroborreliosis. In this retrospective study, medical records of patients with acute polyradiculoneuritis hospitalized at University Department of Neurology, Sestre milosrdnice University Hospital Center during a 4-year period were analyzed. The study included data on 27 patients. Definitive diagnosis ofGBS was made in 23 patients and of neuroborreliosis in four (14.8%) patients. Acute inflammatory demyelinating polyneuropathy was recorded in 69% of GBS patients, Miller Fisher syndrome in four patients, and acute motor axonal neuropathy and/or acute motor and sensory axonal neuropathy in three patients. Clinically, patients with neuroborreliosis manifested flaccid tetraparesis, peripheral facial nerve paresis, bulbar paresis, ocular motility disorders, and sensory symptoms of radicular pain and paresthesias. Considering the relatively high prevalence of neuroborreliosis in north-west Croatia, it is important to exclude meningoradiculoneuritis caused by Borrelia burgdorferi on differential diagnosis of GBS in these patients.

Dermatomyositis and polyradiculoneuritis, a rare association

The association between dermatomyositis and polyradiculoneuritis is rarely citated in the speciality literature. Our patient had at first a disorder that looked like dermatomyositis, then she associated polyradiculoneuritis. At the presentation to our hospital the two diseases were combined, being very difficult to differentiate. The discrimination between these two had been made by performing a muscular biopsy and EMG studies. This emphasizes once again their importance in defining the muscular impairment from the neurogenic one.

Epidemiologic investigation of immune-mediated polyradiculoneuropathy among abattoir workers exposed to porcine brain

Background

In October 2007, a cluster of patients experiencing a novel polyradiculoneuropathy was identified at a pork abattoir (Plant A). Patients worked in the primary carcass processing area (warm room); the majority processed severed heads (head-table). An investigation was initiated to determine risk factors for illness.

Methods and Results

Symptoms of the reported patients were unlike previously described occupational associated illnesses. A case-control study was conducted at Plant A. A case was defined as evidence of symptoms of peripheral neuropathy and compatible electrodiagnostic testing in a pork abattoir worker. Two control groups were used - randomly selected non-ill warm-room workers (n = 49), and all non-ill head-table workers (n = 56). Consenting cases and controls were interviewed and blood and throat swabs were collected. The 26 largest U.S. pork abattoirs were surveyed to identify additional cases. Fifteen cases were identified at Plant A; illness onsets occurred during May 2004–November 2007. Median age was 32 years (range, 21–55 years). Cases were more likely than warm-room controls to have ever worked at the head-table (adjusted odds ratio [AOR], 6.6; 95% confidence interval [CI], 1.6–26.7), removed brains or removed muscle from the backs of heads (AOR, 10.3; 95% CI, 1.5–68.5), and worked within 0–10 feet of the brain removal operation (AOR, 9.9; 95% CI, 1.2–80.0). Associations remained when comparing head-table cases and head-table controls. Workers removed brains by using compressed air that liquefied brain and generated aerosolized droplets, exposing themselves and nearby workers. Eight additional cases were identified in the only two other abattoirs using this technique. The three abattoirs that used this technique have stopped brain removal, and no new cases have been reported after 24 months of follow up. Cases compared to controls had higher median interferon-gamma (IFNγ) levels (21.7 pg/ml; vs 14.8 pg/ml, P<0.001).

Discussion

This novel polyradiculoneuropathy was associated with removing porcine brains with compressed air. An autoimmune mechanism is supported by higher levels of IFNγ in cases than in controls consistent with other immune mediated illnesses occurring in association with neural tissue exposure. Abattoirs should not use compressed air to remove brains and should avoid procedures that aerosolize CNS tissue. This outbreak highlights the potential for respiratory or mucosal exposure to cause an immune-mediated illness in an occupational setting.

[Inflammatory neuropathies and multineuritis]

Inflammatory neuropathies include those neuropathies in which the diagnosis, outcome and type of treatment are badly known, the reason of this review. They are expressed as diffuse (such as CIDP and ganglionopathies), multifocal (vasculitic neuropathy) or focal (MMN; plexopathies; immune reconstitution inflammatory syndrome). These forms of neuropathies are important to be known because the beneficial therapeutic possibilities of immunosuppression.

Intravenous immunoglobulin treatment successfully improved subacute progressive polyradiculoneuropathy with polyclonal gammopathy

The present case was an elderly man with a history of gastric cancer, diffuse biliary duct stenosis and liver cirrhosis. He had markedly elevated IgG, suggesting chronic infection or inflammatory changes in the biliary duct. He developed weakness in his arms and became unable to use his hands within one month and 2 weeks later, he had difficulty walking. Based on his progressive disease course, elevated serum IgG, nerve conduction study and enhanced MRI findings, we diagnosed him as suffering from immune-mediated subacute polyradiculoneuropathy with polyclonal gammopathy, which might be related to Guillain-Barré syndrome. Intravenous immunoglobulin (IVIg) was dramatically effective in this patient. In the follow-up 6 months later he was stable and could walk without a cane. Even in patients with polyclonal gammopathy in chronic inflammatory disease of another organ, IVIg may be effective and beneficial for the patients's quality of life.

[Dysimmune neuropathies: current diagnosis and therapy]

Dysimmune neuropathies encompass an acute form, Guillain-Barré syndrome (GBS), and mainly 3 chronic forms: chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), multifocal motor neuropathy, and polyneuropathy associated with anti-MAG (myelin-associated-glycoprotein) IgM monoclonal gammopathy. Recent concepts have concerned both incidence and mortality rates, and better scoring system for predict outcome in GBS, but new therapeutical strategy is needed for the so-called "benign" forms and for relapsing forms after first-line IVIg therapy. In chronic forms, criteria for diagnosis and guidelines for management have been edited in the recent years, together with recommendations for outcome measures. However, there is still a need for knowing the better outcome measures, and to elaborate new trials, mainly focusing on the long-term management of the patients.

[What is a peripheral neuropathy?]

Peripheral neuropathies may be classified according to the localisation of symptoms and signs. This step necessitates a good knowledge of the peripheral nervous system anatomy. The diagnostic strategy relies on this classification and allows, thanks to the neurophysiological exam to establish the pathogenic mechanism of the neuropathy. These data are important to limit the possible aetiologies to a reasonable number in order to use the appropriate paraclinical work-up. Laboratory examinations may be simple or sophisticated and their use may require the help of an expert center. In a limited number of cases, nerve biopsy is still a very useful tool to determinate the mechanism of peripheral neuropathy and to guide the treatment.

Magnetic resonance imaging findings in chronic inflammatory demyelinating polyneuropathy with intracranial findings and enhancing, thickened cranial and spinal nerves

Chronic inflammatory demyelinating polyneuropathy is a rare autoimmune disorder characterized by chronically progressive or relapsing symmetric sensorimotor involvement. We describe the imaging findings in our patient. Magnetic resonance imaging showed presence of an intracranial white matter lesion and enhancing, thickened cranial and spinal nerves. This disorder has been described very infrequently in the radiology literature.

[Electrophysiological diagnosis of inflammatory neuropathies]

Electrodiagnostic study is very important in the diagnosis of inflammatory neuropathies with clinical, biological or histopathological criterias. It initially affirms the existence of a neuropathy and then to define if the pathological process is demyelinating, axonal or more rarely mixed. It also specifies if it concerns only sensory fibers, motor fibers or both. This exploration thus will make it possible to define different sub-groups with, for each one, a possible etiological guidelines. In the subgroup of demyelinating neuropathies, except congenital neuropathies, the inflammatory neuropathies represent the main étiology with chronic infammatory demyelinating polyneuropathy as a model. In the group of axonal neuropathies, inflammatory etiology is not prevailing. But, according to the subtype of neuropathy (sensory, motor or mixed) and the possible asymmetrical presentation, it could be however possible to extract different electrophysiological entities and to guide the clinician towards various sub-groups among which the inflammatory etiologies are sometimes largely dominating (mononeuritis multiplex and ganglionopathies for example).

Recurrence of childhood Guillain-Barré syndrome after a long asymptomatic interval: a case report

We present a patient who rapidly developed flaccid paralysis in all 4 limbs on 2 separate occasions 19 years apart. Each episode was accompanied by a respiratory failure that required intubation. Both times, clinical response to immunotherapy was favorable with a near complete recovery. Clinical course, laboratory and electrodiagnostic findings, and favorable response to therapy suggest 2 separate attacks of Guillain-Barré syndrome. The reported case adds to a small series of cases of recurrent Guillain-Barré syndrome after a long asymptomatic period. In such cases, the distinction from chronic inflammatory demyelinating polyradiculoneuropathy should be made.

Vincristine-induced acute neurotoxicity versus Guillain?Barr� syndrome: a diagnostic dilemma

We report the case of a patient with acute lymphoblastic leukaemia who, after the initiation of treatment with vincristine (VCR), developed a fulminant motor polyradiculoneuropathy resembling an axonal variant of Guillain-Barré syndrome (GBS). This report shows that differentiating between axonal GBS and VCR-induced acute neurotoxicity may be a challenge for clinicians.

Classifications and treatment responses in chronic immune-mediated demyelinating polyneuropathy

BACKGROUND

Chronic immune-mediated demyelinating polyneuropathy (CIP) represents a heterogeneous pool of motor, sensory, sensorimotor, symmetric, or asymmetric syndromes.

OBJECTIVE

To evaluate published diagnostic classifications and characterize predictors of treatment response.

METHODS

One hundred two of 158 patients with a working diagnosis of CIP were included and clinically characterized because they had electrophysiologic and/or histologic evidence of demyelination. The biostatistical profile of patients with symmetric clinical manifestation was analyzed using three proposed classifications (American Academy of Neurology [AAN] criteria, modified AAN criteria, European Federation of Neurological Societies/Peripheral Nerve Society [EFNS/PNS] criteria). Treatment responses to IV immunoglobulins (IVIg) and their positive predictors were investigated.

RESULTS

Sensitivities (0.52 [AAN] vs 0.83 [modified AAN] vs 0.95 [EFNS/PNS]) and negative predictive values (0.68 vs 0.85 vs 0.92) differed markedly, whereas specificities (0.94 vs 0.90 vs 0.96) and positive predictive values (0.89 vs 0.89 vs 0.97) were similar. In CIP patients treated with IVIg, a positive response was found in 62 of 76 (82%). Patients with a monophasic or relapsing-remitting course or a more than twofold CSF protein increase had the highest probability to respond to IVIg, most evident when using the modified AAN criteria.

CONCLUSIONS

The European Federation of Neurological Societies/Peripheral Nerve Society criteria for chronic inflammatory demyelinating polyneuropathy improve treatment of patients with chronic immune-mediated demyelinating polyneuropathy, particularly with respect to diagnostic issues. To predict IV immunoglobulin treatment response, the modified American Academy of Neurology criteria are the most valuable classification provided an increased CSF protein level.

Acute motor sensory polyneuropathy (AMSAN) complicating active ulcerative colitis with a patchy distribution

We report a case of acute motor and sensory neuropathy during a flare of ulcerative colitis. A 28-year-old male presented with a flare of distal ulcerative colitis despite treatment with mesalamine enemas and suppositories simultaneously with rapidly deteriorating weakness and needle sensation in both legs. Neurological assessment showed axonal sensorimotor polyneuropathy affecting mainly the lower limbs and to a lesser extent the upper limbs. Colonoscopy revealed moderately to severe active ulcerative colitis with a patchy distribution involving the rectum and the right colon. Vitamin and folic acid levels were normal. Virological, immunological and other laboratory tests were negative except for positive anti-ganglioside antibodies (anti-GM1). Ulcerative colitis and polyneuropathy improved when patient was treated with immunosuppressive therapy (corticosteroids, immunoglobulin and azathioprine). Peripheral polyneuropathy is a rare extraintestinal manifestation of ulcerative colitis and it is probably associated with an autoimmune pathogenetic mechanism.

Chronic inflammatory demyelinating polyradiculopathy: an atypical pediatric case complicated with phrenic nerve palsy

An atypical form of chronic inflammatory demyelinating polyneuropathy (CIDP) complicated with phrenic nerve palsy is presented with clinical and electrophysiologic features. A seven-year-old girl had initial presentation mimicking Guillain-Barré syndrome based on electrophysiologic characteristics. Between 7-11 years of age, she had five recurrences of subacute onset of weakness which usually developed over at least 2-4 months and progressed to loss of ambulation and to respiratory insufficiency. Radiologic examinations revealed unilateral phrenic nerve palsy associated with CIDP. Our patient demonstrated the rare association of CIDP and phrenic nerve palsy, resulting in diaphragmatic paralysis and respiratory failure.

Multiorgan involvement due to cytomegalovirus infection in AIDS

Cytomegalovirus (CMV) infection is a relatively late complication of AIDS. Like other viruses contributing to co-morbidity of HIV infection, cytomegalovirus has the propensity to cause multiorgan involvement. We report the case of a 34-year-old seropositive man who presented with bilateral lower limb weakness and symptomatic pallor. He was already on antiretroviral drugs for a month prior to presentation. Detailed clinical examination and laboratory investigations revealed cytomegalovirus polyradiculoneuropathy associated with bone marrow dysplasia. Dysplasia of haematopoeitic cell lines occurs in 30% to 70% of HIV infected patients, and is often indistinguishable from myelodysplastic syndrome. However, in our case, the bone marrow picture reverted back to normal with treatment of the CMV infection, pointing to a possible role of CMV as the causative agent of bone marrow dysplasia. Moreover, CMV has been incriminated as a pathogen producing the immune reconstitution inflammatory syndrome. The onset of the disease in our case one month after initiation of HAART strongly raises the possibility of this being a case of CMV related IRIS. This is the first reported case where IRIS has presented with CMV polyradiculoneuropathy and bone marrow dysplasia. We would like to highlight that in today's era of HIV care, clinicians should be aware of the possibility of multiorgan involvement by CMV, for appropriate management of this disease in the background of AIDS.

Diabetic Neuropathy, The Great Masquerader: Truncal Neuropathy Manifesting as Abdominal Pseudohernia

OBJECTIVE

To describe a patient with diabetic truncal neuropathy and suggest a helpful diagnostic approach to this entity.

METHODS

We present a case report, with a focus on physical, computed tomographic, and electromyographic findings.

RESULTS

Because of an extensive differential diagnosis, diabetic truncal neuropathy is a rarely recognized and often misdiagnosed condition in patients with diabetes mellitus. In a 55-year-old man with a 13-year history of diabetes but no retinopathy, vasculopathy, or nephropathy, pain and a visible bulge in the left lower abdominal quadrant prompted radiographic assessment of the abdomen. A computed tomographic scan of the abdomen disclosed no mass but a weakening of the abdominal musculature suggestive of a pseudohernia. Subsequent electromyography showed evidence of polyradicular neuropathy. The patient was given treatment for pain control, and the pseudohernia resolved within 1 year.

CONCLUSION

In patients with diabetes who have a painful abdominal mass, the potential presence of a diabetic truncal neuropathy should be considered.

Les limites cliniques du concept de polyradiculonévrite chronique

BACKGROUND

Chronic inflammatory demyelinating polyradiculoneuropathy is an autoimmune disease that target myelin sheats of peripheral nerves. Its diagnosis is often difficult to make, and a number of cases are probably not identified because of the clinical heterogeneity. Numerous sets of diagnostic criteria have sought to define CIDP but clinical criteria are generally not detailed.

OBJECTIVES

To review the main clinical characteristics suggestive of CIDP (that means not compatible with a length-dependent axonal process) and the critical clinical points of the neuropathy which make the differential diagnosis with the main other forms of chronic auto immune neuropathy sometimes difficult.

RESULTS

The main clinical characteristic are: a symmetric proximal and distal motor weakness predominantly affecting the lower limbs, a diffuse areflexia, a sensory deficit characterized by a preferential involvement of large fibers, an evolution which may be either chronic progressive or recurrent. These aspects raise many questions concerning overlap with other inflammatory neuropathies such as Guillain Barre syndrome, Lewis-Sumner neuropathy, chronic ataxic neuropathy. The distinction of a subgroup of CIDP associated with other diseases such as diabetes or HIV are also controversial.

CONCLUSION

The growing body of knowledge on the pathogenesis of CIDP and clinical or electrophysiological differentiation of subforms may help to develop more effective therapies for CIDP in the next few years.

Joint Task Force of the EFNS and the PNS+. European Federation of Neurological Societies/Peripheral Nerve Society Guideline* on management of paraproteinemic demyelinating neuropathies. Report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society

BACKGROUND

Paraprotein-associated neuropathies have heterogeneous clinical, neurophysiological, neuropathological, and hematological features.

OBJECTIVES

The aim of this guideline was to prepare evidence-based and consensus guidelines on the clinical management of patients with both a demyelinating neuropathy and a paraprotein [paraproteinemic demyelinating neuropathy (PDN)].

METHODS

Disease experts and a representative of patients considered references retrieved from MEDLINE and the Cochrane Library and prepared statements that were agreed in an iterative fashion.

RECOMMENDATIONS

In the absence of adequate data, evidence-based recommendations were not possible, but the Task Force agreed on the following good practice points: (1) patients with PDN should be investigated for a malignant plasma cell dyscrasia; (2) the paraprotein is more likely to be causing the neuropathy if the paraprotein is immunoglobulin M (IgM), antibodies are present in serum or on biopsy, or the clinical phenotype is chronic distal sensory neuropathy; (3) patients with IgM PDN usually have predominantly distal and sensory impairment, with prolonged distal motor latencies, and often anti-myelin-associated glycoprotein antibodies; (4) IgM PDN sometimes responds to immunotherapies. Their potential benefit should be balanced against their possible side effects and the usually slow disease progression; (5) IgG and IgA PDN may be indistinguishable from chronic inflammatory demyelinating polyradiculoneuropathy clinically, electrophysiologically, and in response to treatment; and (6) for POEMS syndrome, local irradiation or resection of an isolated plasmacytoma, or melphalan with or without corticosteroids, should be considered, with hemato-oncology advice.

Subacute inflammatory demyelinating polyneuropathy in children

Reported are five children with subacute demyelinating polyneuropathy. All patients had a monophasic disease, progressing over 4 to 8 weeks and characterized by predominantly motor features, areflexia, minimal or no cranial nerve abnormalities, no autonomic or respiratory involvement, elevated CSF protein, electrophysiologic evidence of demyelination, and good response to corticosteroids. A benign course with full recovery was the rule.

Multifocal motor sensory demyelinating neuropathy: Inflammatory demyelinating polyradiculoneuropathy

The authors present two cases that provide the first autopsy findings in multifocal acquired demyelinating sensory and motor neuropathy (MADSAMN). Both cases documented multifocal but asymmetric demyelinating neuropathy with rare axonal degeneration. One case clearly documented an inflammatory polyradiculoplexoneuropathy, confirming the inflammatory nature of this neuropathy. This study showed that MADSAMN is an inflammatory demyelinating polyradiculoneuropathy that shares histologic features observed in chronic inflammatory demyelinating polyradiculoneuropathy and multifocal motor neuropathy (MMN), suggesting a similar immunopathogenesis for these entities.

[Non-traumatic acute transverse spinal cord syndromes]

Differential diagnosis of non-traumatic, acute transverse spinal cord syndromes should cover compressive myelopathy (mostly hematomas or tumors), inflammatory myelitis and vascular myelopathies. Since acute pathologies of the spinal cord primarily result in flaccid para- or tetraparesis accompanied by areflexia or hyporeflexia (spinal shock), acute polyradiculoneuritis and the cauda equina syndrome must also be weighed into the differential diagnosis. Paraplegia may ultimately also be of psychogenic origin. The clinical picture is characterized by the rapidity of progression, the possible involvement of pain, and the specific pattern of the deficits. When the latter occurs, localization of the rostrocaudal level and transverse spread are crucial factors. Depending on the affected structure, one differentiates between anterior spinal cord syndromes (anterior spinal artery syndrome, selective involvement of the anterior horn, centromedullary syndromes), long pathway syndrome (isolated in the posterior bundle or combined with pyramidal pathways) and the unilateral Brown-Séquard's syndrome. Infectious myelitis is usually caused by neurotropic viruses or mycoplasmata in conjunction with meningitis or encephalitis; these in turn either induce transverse myelitis accompanied by severe sensomotor deficits or chiefly affect the gray matter, then producing a pattern similar to anterior spinal artery syndrome. In the case of non-infectious inflammatory myelitis, one must differentiate between multiple sclerosis, acute disseminated encephalomyelitis (ADEM), idiopathic transverse myelitis and that of the neuromyelitis optica or Devic's disease. Symptomatic transverse myelitis can also be present in association with connective tissue diseases (e.g. SLE, Behçet's disease, Sjögren's syndrome) or sarcoidosis. Notably, when ischemic spinal infarcts are involved, their onset is frequently painful and their manifestation typically subacute, rather than apoplectiform.

"A girdle-like tightening sensation" misapprehended as abdominal splanchnopathy in a sarcoidosis patient

We describe a 53-year-old man with the isolated manifestation of girdle-like tightening sensation of the trunk due to polyradiculopathy at the beginning of sarcoidosis which was first misapprehended as abdominal splanchnopathy. Late development of other neurological and systemic symptoms led to the final diagnosis of sarcoidosis. Segmental dysesthesia at the trunk in neurosarcoidosis is unique and may mimic a splanchnic pain. Such a dysesthesia may be solely manifested at the beginning of sarcoidosis and may continue for days without other symptoms. When patients complain of a girdle-like tightening with unknown etiology, sarcoidosis should be suspected as the possible cause.

Multifocal motor neuropathy

Multifocal motor neuropathy (MMN) is an immune-mediated disorder characterised by slowly progressive, asymmetrical weakness of limbs without sensory loss. The clinical presentation of MMN mimics that of lower-motor-neuron disease, but in nerve-conduction studies of patients with MMN motor-conduction block has been found. By contrast with chronic inflammatory demyelinating polyneuropathy, treatment with prednisolone and plasma exchange is generally ineffective in MMN and even associated with clinical worsening in some patients. Of the immunosuppressants, cyclophosphamide has been reported as effective but only anecdotally. Various open trials and four placebo-controlled trials have shown that treatment with high-dose intravenous immunoglobulin leads to improvement of muscle strength in patients with MMN. Although clinical, pathological, imaging, immunological, and electrophysiological studies have improved our understanding of MMN over the past 15 years, further research is needed to elucidate pathogenetic disease mechanisms in the disorder.

IgM deposits on skin nerves in anti-myelin-associated glycoprotein neuropathy

Anti-myelin-associated glycoprotein (anti-MAG) neuropathy is a chronic demyelinating neuropathy with predominant involvement of large sensory fibers and deposits of IgM and complement on sural nerve myelinated fibers. We assessed the presence of IgM deposits on skin myelinated nerve fibers and the involvement of unmyelinated axons in anti-MAG neuropathy. Skin biopsies were performed in 14 patients with anti-MAG neuropathy, in 8 patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), and in 2 patients with IgM paraproteinemic neuropathy. Biopsies were taken at the proximal thigh in 20 patients, at the distal leg in 21 patients, at the proximal arm in 13 patients, and at the hand or fingertip in 10 patients. We found IgM deposits on dermal myelinated fibers in all anti-MAG neuropathy patients, with a greater prevalence at the distal site of the extremities. Deposits were located throughout the length of the fibers and at the paranodal loops. CIDP and IgM paraproteinemic neuropathies did not show any deposit of IgM. Anti-MAG neuropathy and CIPD patients showed a decrease in epidermal nerve fiber density reflecting an associated axonal loss. In anti-MAG neuropathy, both large- and small-diameter nerve fibers are affected, and specific deposits of IgM are found on skin myelinated nerve fibers.

Characterization of neuropathies associated with elevated IgM serum levels

BACKGROUND

In contrast to the IgM monoclonal gammopathies the neuropathy associated with polyclonal IgM gammopathy has not been well characterized.

OBJECTIVE

To characterize the neuropathy in patients with elevated serum IgM.

DESIGN

Retrospective review.

SETTING

Academically based neuropathy center.

PATIENTS

45 patients with elevated quantitative immunoglobulin M were identified.

MAIN OUTCOME MEASURES

Patients are described with regard to clinical phenotype, electrodiagnostic features of demyelination or focality, presence of IgM monoclonal gammopathy, and presence of autoantibody activity.

RESULTS

Elevated IgM levels occurred in 45 (11.5%) of 391 patients. Of these, 24 (53%) had polyclonal gammopathy and 21 (47%) had an IgM monoclonal gammopathy. Anti-nerve antibodies occurred in 14/21 (67%) of patients with monoclonal gammopathy, as compared to 1/24 (4%) with polyclonal gammopathy. Clinically, most patients in all groups had a predominantly large fiber sensory neuropathy. Thirty patients underwent electrodiagnostic testing. Of these, 22/30 (73%) fulfilled at least one published criteria for CIDP, including 92% of the monoclonal gammopathy patients and 59% of the polyclonal gammopathy patients. Fifteen of the 30 patients had evidence of focality or multifocality, with 14 of these 15 showing evidence of demyelination.

CONCLUSIONS

Monoclonal and polyclonal IgM patients have similar distributions of neuropathy phenotypes. Neuropathy in association with elevated serum IgM, with or without monoclonal gammopathy or autoantibody activity, is more likely to be demyelinating or multifocal. Serum quantitative IgM level and immunofixation in neuropathy patients may aid in identification of an immune mediated or a demyelinating component.

[Diagnosis and management of immune-mediated neuropathies]

Immune-mediate neuropathies, or inflammatory neuropathies are neuropathies due to the dysregulation of the immune system. The injury to peripheral nerves can be divided into two phases: an early stage of immune injury, and a later stage of structural damage. The overall effects are axonal degeneration or demyelination depending on the target of immunological attacks. According to time course, there are two major types: Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP). Clinical manifestations of both diseases include progressive motor weakness and sensory disturbance with some variations among different patients. The major findings of nerve conduction studies on GBS patients are prolonged distal motor latencies and minimal F-wave latencies with variable reduction of nerve conduction velocities. In CIDP patients, slowed nerve conduction velocities are the usual findings in addition to prolongation of distal motor latencies and minimal F-wave latencies. Certain subtypes of immune-mediated neuropathies are associated with high titers of anti-gangliosdie antibodies. Patients with GBS and CIDP can benefit from immunotherapy. For GBS, plasma exchange and intravenous immunoglobulin (IVIG) are equally effective in reducing complications and neurological disability. Steroid of high dose is, however, harmful to GBS. Plasma exchange and IVIG can alleviate neurological deficits of CIDP with steroid to maintain the effects of plasma exchange and IVIG. In conclusion, careful clinical observations and judgment are the most important issue to manage patients with immune-mediated neuropathies.

Clinical presentations of peripheral neuropathies

This article addresses the clinical presentations of different peripheral neuropathies. The topic is discussed briefly with emphasis on the most important clinical features. MR imaging of the peripheral nerves is a rapidly advancing field, and it is hoped that the basic understanding of the clinical presentations of peripheral neuropathies will encourage radiologists to get more involved in MR imaging of the peripheral nerves.

Distinguishing PANDAS from Sydenham's chorea: case report and review of the literature

Children with Sydenham's chorea and PANDAS (Pediatric autoimmune neuropsychiatric disorders associated with streptococcal throat infections) share an array of neuropsychiatric symptoms and distinguishing one from the other, especially at onset can prove challenging. It is, however, important to distinguish between these two post-streptococcal disorders since their response to therapy differs. Children with Sydenham's chorea require long-term benzathine penicillin prophylaxis to reduce the risk of rheumatic heart disease. In contrast, the efficacy of penicillin prophylaxis in preventing tic or obsessive-compulsive symptom exacerbations in children with PANDAS remains doubtful. Immunomodulatory therapies such as plasma exchange and intravenous immunoglobulin have shown to reduce neuropsychiatric symptom severity in children with PANDAS. Tonsillectomy may also represent an effective treatment option in children severely affected by PANDAS. We present this case to demonstrate the pitfalls in differentiating between these two closely associated conditions in a developing country where the prevalence of rheumatic fever is high.