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Fischer F, Dohrn MF, Kapfenberger R, Igharo D, Seeber D, de Moya Rubio E, Pitarokoili K, Börsch N, Mücke M, Rolke R, Schulz JB, Maier A. [Neuropathic pain as a symptom in autonomic neuropathies and other rare diseases : Small fiber neuropathy: its recognition, diagnosis, and treatment]. Schmerz 2024; 38:33-40. [PMID: 38197939 DOI: 10.1007/s00482-023-00783-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Neuropathic pain is difficult to diagnose and treat. Small fiber neuropathy (SFN) flies under the radar of nerve conduction studies. OBJECTIVES The importance of a structured patient history and physical examination in the context of neuropathic pain is emphasized. Describing SFN as an important cause, the authors consider rare but partially treatable differential diagnoses. They conclude that autonomic symptoms are frequently associated, often presenting with diverse symptoms. METHODS A selective literature research to present SFN symptoms as well as differential diagnostic and therapeutic steps in the context of SFN and rare diseases focusing on the autonomic nervous system. RESULTS Neuropathic pain significantly reduces quality of life. To shorten the time until diagnosis and to initiate therapy, the authors recommend a structured patient history including sensory plus and minus symptoms and non-specific autonomic signs. If the initial search for the cause is not successful, rare causes such as treatable transthyretin (ATTR) amyloidosis and Fabry's disease or autoimmune causes should be considered, particularly in the case of progressive and/or autonomic symptoms. CONCLUSION The diagnosis and therapy of rare SFN requires interdisciplinary collaboration and, in many cases, a referral to specialized centers to achieve the best patient care.
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Affiliation(s)
- Fiona Fischer
- Klinik für Neurologie, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
| | - Maike F Dohrn
- Klinik für Neurologie, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
| | - Romina Kapfenberger
- Klinik für Neurologie, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
| | - Denver Igharo
- Klinik für Neurologie, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
- Hals-Nasen-Ohren-Klinik, Helios Klinikum Krefeld, Krefeld, Deutschland
| | - Diana Seeber
- Klinik für Neurologie, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
| | - Elena de Moya Rubio
- POTS und andere Dysautonomien e. V., Bochum, Deutschland
- Marfan Hilfe (Deutschland) e. V., Olpe, Deutschland
| | - Kalliopi Pitarokoili
- Neurologische Universitätsklinik am St. Josef Hospital Katholisches Klinikum Bochum, Bochum, Deutschland
| | - Natalie Börsch
- Institut für Digitale Allgemeinmedizin, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
- Zentrum für Seltene Erkrankungen Aachen (ZSEA), Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
| | - Martin Mücke
- Institut für Digitale Allgemeinmedizin, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
- Zentrum für Seltene Erkrankungen Aachen (ZSEA), Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
| | - Roman Rolke
- Klinik für Palliativmedizin, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
| | - Jörg B Schulz
- Klinik für Neurologie, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
- JARA-BRAIN Institut II, Institut für Neurowissenschaften und Medizin, Forschungszentrum Jülich GmbH und RWTH Aachen, Jülich, Deutschland
| | - Andrea Maier
- Klinik für Neurologie, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland.
- POTS und andere Dysautonomien e. V., Bochum, Deutschland.
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Yamasaki R. [Small Fiber Neuropathy with Inadequate Response to Medical Therapy: Diagnosis of The Etiology of Small Fiber Neuropathy and Treatment Option]. Brain Nerve 2022; 74:608-613. [PMID: 35589654 DOI: 10.11477/mf.1416202087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Small-fiber neuropathy (SFN) has few significant laboratory findings and is difficult to diagnose. In 70% of the cases, the cause of SFN is unknown. Among the cases with known etiology, 50% are associated with diabetes, and the causes are autoimmune, amyloidosis, or multifactorial. In recent years, a specific autoantibody-positive group has been identified and has attracted attention because immunotherapy was successful in the autoantibody-positive SFN groups. In the cases reporting to our department, abnormalities could not be detected by various tests, including nerve conduction studies, and the response to symptomatic treatment was poor. An abnormality was identified in the current perception threshold test result, and a positive blood anti-plexin D1 antibody was detected via enzyme-linked immunosorbent assay. Therefore, autoimmune SFN was diagnosed, and plasma exchange therapy was remarkably effective. Subsequently, we aim to introduce general treatments for SFN and COVID-19-related SFN.
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Affiliation(s)
- Ryo Yamasaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
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Strand N, Wie C, Peck J, Maita M, Singh N, Dumbroff J, Tieppo Francio V, Murphy M, Chang K, Dickerson DM, Maloney J. Small Fiber Neuropathy. Curr Pain Headache Rep 2022; 26:429-438. [PMID: 35384587 DOI: 10.1007/s11916-022-01044-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW This narrative review aims to summarize advances in the field of small fiber neuropathy made over the last decade, with emphasis on novel research highlighting the distinctive features of SFN. RECENT FINDINGS While the management of SFNs is ideally aimed at treating the underlying cause, most patients will require pain control via multiple, concurrent therapies. Herein, we highlight the most up-to-date information for diagnosis, medication management, interventional management, and novel therapies on the horizon. Despite the prevalence of small fiber neuropathies, there is no clear consensus on guidelines specific for the treatment of SFN. Despite the lack of specific guidelines for SFN treatment, the most recent general neuropathic pain guidelines are based on Cochrane studies and randomized controlled trials (RCTs) which have individually examined therapies used for the more commonly studied SFNs, such as painful diabetic neuropathy and HIV neuropathy. The recommendations from current guidelines are based on variables such as number needed to treat (NNT), safety, ease of use, and effect on quality of life.
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Affiliation(s)
- N Strand
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA.
| | - C Wie
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - J Peck
- Performing Arts Medicine Department, Shenandoah University, Winchester, USA
| | - M Maita
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - N Singh
- OrthoAlabama Spine and Sports, Birmingham, AL, USA
| | - J Dumbroff
- Mount Sinai Morningside and West Department of Anesthesiology, New York, NY, USA
| | - V Tieppo Francio
- Department of Rehabilitation on Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - M Murphy
- Department of Rehabilitation on Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - K Chang
- Department of Anesthesiology and Critical Care, Emory University, Atlanta, GA, USA
| | - D M Dickerson
- NorthShore University HealthSystem, Evanston, IL, USA
- University of Chicago Medicine, Chicago,, IL, USA
| | - J Maloney
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA
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Häuser W. Facts and myths pertaining to fibromyalgia. Dialogues Clin Neurosci 2018; 20:53-62. [PMID: 29946212 PMCID: PMC6016048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
Fibromyalgia (FM) is characterized by chronic widespread pain, unrefreshing sleep, physical exhaustion, and cognitive difficulties. It occurs in all populations throughout the world, with prevalence between 2% and 4% in general populations. Definition, pathogenesis, diagnosis, and treatment of FM remain points of contention, with some even contesting its existence. The various classification systems according to pain medicine, psychiatry, and neurology (pain disease; persistent somatoform pain disorder; masked depression; somatic symptom disorder; small fiber neuropathy; brain disease) mostly capture only some components of this complex and heterogeneous disorder. The diagnosis can be established in most cases by a general practitioner when the symptoms meet recognized criteria and a somatic disease sufficiently explaining the symptoms is excluded. Evidence-based interdisciplinary guidelines give a strong recommendation for aerobic exercise and cognitive behavioral therapies. Drug therapy is not mandatory. Only a minority of patients experience substantial symptom relief with duloxetine, milnacipran, and pregabalin.
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Affiliation(s)
- Winfried Häuser
- Department Internal Medicine 1, Klinikum Saarbrücken, Saarbrücken, Germany. Department Psychosomatic Medicine and Psychotherapy, Technische Universität München, München, Germany
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Maino P, Koetsier E, Kaelin-Lang A, Gobbi C, Perez R. Efficacious Dorsal Root Ganglion Stimulation for Painful Small Fiber Neuropathy: A Case Report. Pain Physician 2017; 20:E459-E463. [PMID: 28339448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Small fiber neuropathy is a disorder of the peripheral nerves with typical symptoms of burning, sharp, and shooting pain and sensory disturbances in the feet. Pain treatment depends principally on the underlying etiology with concurrent administration of antidepressants, anticonvulsants, opioids, and topical treatments like capsaicin and local anesthetics. However, treatments for pain relief in these patients frequently fail. We describe the first case of intractable painful small fiber neuropathy of the foot successfully treated with spinal cord stimulation of the left L5 dorsal root ganglion.A 74-year-old man presented at our clinic with severe intractable pain, dysesthesia, and allodynia of the left foot caused by idiopathic small fiber neuropathy, confirmed by skin biopsy. His pain score was 8 on a standard 0 - 10 numeric rating scale. As the pain was not satisfactorily controlled by conventional therapy, dorsal root ganglion stimulation was proposed to the patient and, after informed consent, a specifically designed percutaneous stimulation lead was placed over the left L5 dorsal root ganglion and connected to an external neurostimulator. After a positive trial of 10 days, a permanent neurostimulator was implanted. Twenty months post-implantation the patient continued to experience stimulation-induced paresthesia covering the entire pain area and reported a pain rating of 4.Results from the case report demonstrate that the dorsal root ganglion is a promising neural stimulation target to treat neuropathic pain due to intractable small fiber neuropathy. Prospective controlled studies are warranted to confirm the efficacy of this treatment as an option for the aforementioned condition.Key words: Dorsal root ganglion stimulation, small fiber neuropathy, neuropathic pain.
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Affiliation(s)
- Paolo Maino
- Ospedale Regionale di Lugano, Viganello, Switzerland
| | - Eva Koetsier
- Ospedale Regionale di Lugano, Viganello, Switzerland
| | | | - Claudio Gobbi
- Ospedale Regionale di Lugano, Viganello, Switzerland
| | - Roberto Perez
- Department of Anesthesiology, VU University Medical Center, Amsterdam; Trauma Related Neuronal Dysfunction (TREND), Delft; EMGO+ Institute for Health and Care Research, Amsterdam
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