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Coskun O, Sahin H, Yalcin S, Sahin YC, Coskun U. Nivolumab-induced sensory ganglionopathy. J Oncol Pharm Pract 2023; 29:1510-1515. [PMID: 37254496 DOI: 10.1177/10781552231177712] [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] [Indexed: 06/01/2023]
Abstract
INTRODUCTION Nivolumab is s a human monoclonal antibody. Due to its widespread use in many cancers, including Merkel cell carcinoma, adverse reactions associated with nivolumab, such as neuropathies, endocrinopathies, gastrointestinal problems, and skin toxicities have been increasing. Sensory ganlionopathy is rarely observed in these patients. CASE DESCRIPTION We present a 63-year-old male with a medical history of Merkel cell carcinoma that recurred two times in the inguinal region. After undergoing surgery with adjuvant radiotherapy, a second surgery was performed. The patient suffered from tingling in all four limbs plus difficulty in walking after initiation of the third dose of nivolumab. MANAGEMENT AND OUTCOME After 1 month of 1 mg/kg/day methylprednisolone treatment, he showed significant improvement. Subsequently, the systemic corticosteroid regimen was tapered to 5 mg every other day. The treatment resulted in significant improvement in all extremities. DISCUSSION Sensory ganlionopathy can be seen as a side effect of an immune checkpoint inhibitor, even though it is very extraordinary. This is the case in the literature to develop sensory ganlionopathy due to nivolumab. We believe that patients using nivolumab may develop sensory ganlionopathy and management should be taken on this point.
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Affiliation(s)
- Ozlem Coskun
- Department of Neurology, Kirikkale University School of Medicine, Kirikkale, Turkey
| | - Hasan Sahin
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Selim Yalcin
- Department of Neurology, Kirikkale University School of Medicine, Kirikkale, Turkey
| | - Yekta C Sahin
- Department of Nutrition and Dietetics, Ankara Medipol University School of Health Science, Ankara, Turkey
| | - Ugur Coskun
- Department of Neurology, Kirikkale University Faculty of Medicine, Kirikkale, Turkey
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Navickaitė I, Ališauskienė M, Petrauskienė S, Žemgulytė G. Sarcoidosis-Associated Sensory Ganglionopathy and Harlequin Syndrome: A Case Report. Medicina (Kaunas) 2023; 59:1495. [PMID: 37629785 PMCID: PMC10456357 DOI: 10.3390/medicina59081495] [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] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Sensory ganglionopathy is a rare neurological disorder caused by degeneration of the neurons composing the dorsal root ganglia. It manifests as various sensory disturbances in the trunk, proximal limbs, face, or mouth in a patchy and asymmetrical pattern. Harlequin syndrome is characterized by unilateral flushing and sweating of the face, neck, and upper chest, concurrent with contralateral anhidrosis. Here, we present and discuss a clinical case of sarcoidosis-associated ganglionopathy and Harlequin syndrome. Case presentation: A 31-year-old woman complained of burning pain in the right side of the upper chest and the feet. She also experienced episodes of intense flushing and sweating on the right side of her face, neck, and upper chest. Three years before these symptoms began, the patient was diagnosed with pulmonary sarcoidosis. On neurological examination, sensory disturbances were present. In the trunk, the patient reported pronounced hyperalgesia and allodynia in the upper part of the right chest and some patches on the right side of the upper back. In the extremities, hypoalgesia in the tips of the fingers and hyperalgesia in the feet were noted. An extensive diagnostic workup was performed to eliminate other possible causes of these disorders. A broad range of possible metabolic, immunological, and structural causes were ruled out. Thus, the final clinical diagnosis of sarcoidosis-induced sensory ganglionopathy, small-fiber neuropathy, and Harlequin syndrome was made. Initially, the patient was treated with pregabalin and amitriptyline, but the effect was inadequate for the ganglionopathy-induced pain. Therefore, therapeutic plasma exchange as an immune-modulating treatment was selected, leading to partial pain relief. Conclusions: This case report demonstrates the possible autoimmune origin of both sensory ganglionopathy and Harlequin syndrome. It suggests that an autoimmune etiology for these disorders should be considered and the diagnostic workup should include screening for the most common autoimmune conditions.
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Affiliation(s)
- Ieva Navickaitė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, A. Mickeviciaus Str. 9, LT-44307 Kaunas, Lithuania; (M.A.); (G.Ž.)
| | - Miglė Ališauskienė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, A. Mickeviciaus Str. 9, LT-44307 Kaunas, Lithuania; (M.A.); (G.Ž.)
| | - Sandra Petrauskienė
- Department of Preventive and Paediatric Dentistry, Lithuanian University of Health Sciences, Luksos-Daumanto Str. 6, LT-50106 Kaunas, Lithuania;
| | - Gintarė Žemgulytė
- Department of Neurology, Medical Academy, Lithuanian University of Health Sciences, A. Mickeviciaus Str. 9, LT-44307 Kaunas, Lithuania; (M.A.); (G.Ž.)
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Sonkodi B. Psoriasis, Is It a Microdamage of Our "Sixth Sense"? A Neurocentric View. Int J Mol Sci 2022; 23:ijms231911940. [PMID: 36233237 PMCID: PMC9569707 DOI: 10.3390/ijms231911940] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 11/23/2022] Open
Abstract
Psoriasis is considered a multifactorial and heterogeneous systemic disease with many underlying pathologic mechanisms having been elucidated; however, the pathomechanism is far from entirely known. This opinion article will demonstrate the potential relevance of the somatosensory Piezo2 microinjury-induced quad-phasic non-contact injury model in psoriasis through a multidisciplinary approach. The primary injury is suggested to be on the Piezo2-containing somatosensory afferent terminals in the Merkel cell−neurite complex, with the concomitant impairment of glutamate vesicular release machinery in Merkel cells. Part of the theory is that the Merkel cell−neurite complex contributes to proprioception; hence, to the stretch of the skin. Piezo2 channelopathy could result in the imbalanced control of Piezo1 on keratinocytes in a clustered manner, leading to dysregulated keratinocyte proliferation and differentiation. Furthermore, the author proposes the role of mtHsp70 leakage from damaged mitochondria through somatosensory terminals in the initiation of autoimmune and autoinflammatory processes in psoriasis. The secondary phase is harsher epidermal tissue damage due to the primary impaired proprioception. The third injury phase refers to re-injury and sensitization with the derailment of healing to a state when part of the wound healing is permanently kept alive due to genetical predisposition and environmental risk factors. Finally, the quadric damage phase is associated with the aging process and associated inflammaging. In summary, this opinion piece postulates that the primary microinjury of our “sixth sense”, or the Piezo2 channelopathy of the somatosensory terminals contributing to proprioception, could be the principal gateway to pathology due to the encroachment of our preprogrammed genetic encoding.
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Affiliation(s)
- Balázs Sonkodi
- Department of Health Sciences and Sport Medicine, Hungarian University of Sports Sciences, 1123 Budapest, Hungary
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Sancho Saldaña A, Mahdi-Rogers M, Hadden RD. Sensory neuronopathies: A case series and literature review. J Peripher Nerv Syst 2021; 26:66-74. [PMID: 33491284 DOI: 10.1111/jns.12433] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 12/23/2020] [Accepted: 01/15/2021] [Indexed: 11/29/2022]
Abstract
Sensory neuronopathies are heterogeneous disorders of dorsal root ganglia. The clinical and laboratory features in a single-centre series, including response to treatment and outcome have been described. They retrospectively included 54 patients meeting Camdessanché et al (2009) criteria for sensory neuronopathy. The patients were classified according to their likely aetiology and analysed their demographic, clinical, neurophysiological, histological and spinal MRI features. The outcome with the modified Rankin Scale (mRS) was evaluated, and the response to treatment was assessed. About 54 patients were included (18 male; median age 54.5 years). The most common initial symptoms were hypoaesthesia, paraesthesia, ataxia and pain. Half of patients had a slow onset, greater than 12 months before seeing a neurologist. The aetiology as possibly inflammatory (meaning nonspecific laboratory evidence of immune abnormality) in 18 patients (33%), paraneoplastic 8 (15%), autoimmune 7 (13%) and idiopathic 6 (11%) was classified. About 31 patients received immune therapy of which 11 (35%) improved or stabilised. Corticosteroids were the most used treatment (24 patients) and cyclophosphamide had the highest response rate (3/6, 50%). At the final follow up (median 24 months) 67% had mRS ≥3 and 46% mRS ≥4, including 15% who died. Worse outcome was associated with generalised areflexia and pseudoathetosis by logistic regression, and with motor involvement and raised CSF protein by univariate analysis. Sensory neuronopathies caused severe disability, especially in patients with generalised areflexia and pseudoathetosis. Of those without an obvious cause, most had some evidence of dysimmunity. Some patients had a positive response to immunotherapy, but rarely enough to improve disability much.
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Affiliation(s)
- Agustin Sancho Saldaña
- Department of Neurology, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.,Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Mohamed Mahdi-Rogers
- Department of Neurology, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Robert David Hadden
- Department of Neurology, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
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Martinez ARM, de Lima FD, Martins MP, Pereira IE, Miotto N, Mazo DFC, Vigani AG, da Costa LBE, Stucchi RSB, Almeida JRS, Nucci A, França MC. Sensory neuronopathy is a specific and disabling neurological manifestation of autoimmune hepatitis. Eur J Neurol 2020; 27:2072-2078. [PMID: 32441838 DOI: 10.1111/ene.14355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/15/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Neurological manifestations have been identified in the context of autoimmune hepatitis (AIH). Previous case reports highlighted the association between AIH and sensory neuronopathy (SN). Despite that, little is known about the frequency of AIH-related SN and its clinical/neurophysiological profile. Moreover, it is not clear whether SN is an AIH-specific manifestation or related to chronic liver damage. METHODS Seventy consecutive AIH patients were enrolled and their characteristics were compared with 52 consecutive patients with chronic active hepatitis B. All subjects underwent clinical and neurophysiological evaluation. Further comparisons were performed between AIH SN and AIH non-SN patients. RESULTS Mean ages and male:female proportions in the AIH and chronic active hepatitis B groups were 42.2 ± 16.3/51.7 ± 13.6 years and 14:56/29:23, respectively. The frequencies of carpal tunnel syndrome, radiculopathy and polyneuropathy were similar between groups. In contrast, SN was identified only in AIH patients (5/70 vs. 0/52, P = 0.04); the overall prevalence of AIH-related SN was 7% with an average profile of a woman in her 40s with asymmetric onset of sensory deficits that chronically evolved to disabling proprioceptive ataxia associated with marked dysautonomia. Neurological disability and hepatocellular damage did not follow in parallel. Anti-fibroblast growth factor receptor type 3 antibodies were found in 3/5 (60%) of the patients with AIH-related SN. Clinical or demographic predictors of SN in the context of AIH could not be identified. CONCLUSION Sensory neuronopathy, but not other peripheral nervous system diseases, is a specific AIH neurological manifestation. It is often disabling and, in contrast to hepatocellular injury, does not respond to immunosuppression.
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Affiliation(s)
- A R M Martinez
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - F D de Lima
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - M P Martins
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - I E Pereira
- Department of Internal Medicine - Gastroenterology Division (Gastrocentro), University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - N Miotto
- Department of Internal Medicine - Infectious Diseases Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - D F C Mazo
- Department of Internal Medicine - Gastroenterology Division (Gastrocentro), University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - A G Vigani
- Department of Internal Medicine - Infectious Diseases Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - L B E da Costa
- Department of Pathology - Hepatic Disorders Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - R S B Stucchi
- Department of Internal Medicine - Infectious Diseases Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - J R S Almeida
- Department of Internal Medicine - Gastroenterology Division (Gastrocentro), University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - A Nucci
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
| | - M C França
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Sao Paulo, Brazil
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Martinez ARM, Martins MP, Martins CR, Faber I, de Rezende TJR, Nucci A, França MC. Sensory ataxia rating scale: Development and validation of a functional scale for patients with sensory neuronopathies. J Peripher Nerv Syst 2019; 24:242-246. [PMID: 31222873 DOI: 10.1111/jns.12330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 12/18/2022]
Abstract
Sensory neuronopathies (SN) result from dorsal root ganglia damage and manifest with a combination of sensory deficits and proprioceptive ataxia. Characterization of the natural history and development of therapeutic trials are hampered by the lack of clinical scales that capture the whole spectrum of SN-related manifestations. We propose and validate a rating instrument for SN. Three experienced neuromuscular specialists developed items to rate SN. The resultant instrument was later validated by the assessment of the intra-class correlation coefficient, for inter-rater validity in 48 SN patients, and later in a smaller subset of 16 patients to assess its intra-rater validity. Standardized Crombach's alpha and Oblimin rotation analysis were performed to verify internal consistency and items' relationship, respectively. Evaluation of Sensory Ataxia Rating Scale (SEARS)'s external validity was performed by comparison to: scale for the assessment and rating of ataxia (SARA), Beck balance scale (BBS), and INCAT sensory sum score (ISS). A 10-item scale with an intra-class correlation coefficient >0.95 for intra- and inter-rating measurements with a good internal consistency (standardized Cronbach's alpha of 0.83) were observed. There was a normal distribution of the scores without a floor or ceiling effect. A moderate to good correlation between SEARS and SARA, BBS, and ISS was observed. SEARS is a reliable, easy-to-perform and consistent instrument to rate SN. Larger cohorts and multicenter studies are needed to validate its usefulness towards possible treatment trials.
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Affiliation(s)
- Alberto R M Martinez
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Brazil
| | - Melina P Martins
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Brazil
| | - Carlos R Martins
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Brazil
| | - Ingrid Faber
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Brazil
| | - Thiago J R de Rezende
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Brazil
| | - Anamarli Nucci
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Brazil
| | - Marcondes C França
- Department of Neurology - Neuromuscular Division, University of Campinas (UNICAMP), Campinas, Brazil
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Abstract
Weakness and numbness occur in a variety of patterns that reflect injury to different parts of the central and peripheral nervous system. Progressive symptoms most often signify an underlying structural or degenerative problem. Familiarity with the major descending motor and ascending sensory tracts of the central nervous system, as well as radicular (dermatome and myotome) and peripheral nerve anatomy, is essential. Damage to these tracts and nerve fibers produces characteristic clinical symptoms and signs. Imaging, when used in a hypothesis-driven way, can be a valuable adjunct to the clinical history and physical examination. One of the most useful aspects of imaging is that it allows for differentiation of edema and inflammation from gliosis and atrophy, both of which can be associated with progressive weakness or numbness. Compression of nervous system structures by nonnervous system tissue can also be easily detected. The spectrum of diseases and imaging abnormalities associated with progressive weakness and numbness is highlighted in this review via a series of illustrative cases. In each case, anatomic localization and the key imaging findings are emphasized.
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Affiliation(s)
- Joshua P Klein
- Departments of Neurology and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Mongin M, Delorme C, Lenglet T, Jardel C, Vignal C, Roze E. Progressive Ataxia and Palatal Tremor: Think about POLG Mutations. Tremor Other Hyperkinet Mov (N Y) 2016; 6:382. [PMID: 27351300 PMCID: PMC4862008 DOI: 10.7916/d86m36rk] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 04/07/2016] [Indexed: 02/04/2023]
Abstract
Background Progressive ataxia and palatal tremor (PAPT) can be observed in both acquired brainstem or cerebellar lesions and genetic disorders. Phenomenology shown PAPT due to mutation in POLG, the gene encoding the mitochondrial DNA polymerase. Educational value POLG mutation should be considered in patients with PAPT, particularly when additional clues such as a sensory neuronopathy or an ophthalmoplegia are present.
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Affiliation(s)
- Marie Mongin
- CHRU de Tours, Hôpital Bretonneau, Service de Neurologie, Tours, France; Université François Rabelais de Tours, Tours, France
| | - Cécile Delorme
- Département de Neurologie, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France; Inserm U 1127, Sorbonne Universités, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Timothée Lenglet
- Département de Neurophysiologie, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France
| | - Claude Jardel
- AP-HP, Hôpital de la Pitié Salpêtrière, Service de Biochimie Métabolique et Centre de Génétique moléculaire et chromosomique, Paris, France; Inserm U 1016, Institut Cochin, Paris, France
| | - Catherine Vignal
- Neuroophthalmology Department, Rothschild Ophthalmologic Foundation, Paris, France
| | - Emmanuel Roze
- Département de Neurologie, Assistance Publique - Hôpitaux de Paris, Hôpital de la Pitié Salpêtrière, Paris, France; Inserm U 1127, Sorbonne Universités, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
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Abstract
Autoimmune autonomic disorders occur because of an immune response directed against sympathetic, parasympathetic, and enteric ganglia, autonomic nerves, or central autonomic pathways. In general, peripheral autoimmune disorders manifest with either generalized or restricted autonomic failure, whereas central autoimmune disorders manifest primarily with autonomic hyperactivity. Some autonomic disorders are generalized, and others are limited in their anatomic extent, e.g., isolated gastrointestinal dysmotility. Historically, these disorders were poorly recognized, and thought to be neurodegenerative. Over the last 20 years a number of autoantibody biomarkers have been discovered that have enabled the identification of certain patients as having an autoimmune basis for either autonomic failure or hyperactivity. Peripheral autoimmune autonomic disorders include autoimmune autonomic ganglionopathy (AAG), paraneoplastic autonomic neuropathy, and acute autonomic and sensory neuropathy. AAG manifests with acute or subacute onset of generalized or selective autonomic failure. Antibody targeting the α3 subunit of the ganglionic-type nicotinic acetylcholine receptor (α3gAChR) is detected in approximately 50% of cases of AAG. Some other disorders are characterized immunologically by paraneoplastic antibodies with a high positive predictive value for cancer, such as antineuronal nuclear antibody, type 1 (ANNA-1: anti-Hu); others still are seronegative. Recognition of an autoimmune basis for autonomic disorders is important, as their manifestations are disabling, may reflect an underlying neoplasm, and have the potential to improve with a combination of symptomatic and immune therapies.
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Affiliation(s)
- Andrew Mckeon
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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Szmulewicz DJ, McLean CA, MacDougall HG, Roberts L, Storey E, Halmagyi GM. CANVAS an update: clinical presentation, investigation and management. J Vestib Res 2015; 24:465-74. [PMID: 25564090 DOI: 10.3233/ves-140536] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cerebellar Ataxia with Neuropathy and bilateral Vestibular Areflexia Syndrome (CANVAS) is a multi-system ataxia which results in cerebellar ataxia, a bilateral vestibulopathy and a somatosensory deficit. This sensory deficit has recently been shown to be a neuronopathy, with marked dorsal root ganglia neuronal loss. The characteristic oculomotor clinical sign is an abnormal visually enhanced vestibulo-ocular reflex. OBJECTIVE To outline the expanding understanding of the pathology in this condition, as well as diagnostic and management issues encountered in clinical practice. METHODS Retrospective data on 80 CANVAS patients is reviewed. RESULTS In addition to the triad of cerebellar impairment, bilateral vestibulopathy and a somatosensory deficit, CANVAS patients may also present with orthostatic hypotension, a chronic cough and neuropathic pain. Management of falls risk and dysphagia is a major clinical priority. CONCLUSIONS CANVAS is an increasingly recognised cause of late-onset ataxia and disequilibrium, and is likely to be a recessive disorder.
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Affiliation(s)
- David J Szmulewicz
- Royal Victorian Eye & Ear Hospital, University of Melbourne, Melbourne, Australia
| | - Catriona A McLean
- Department of Anatomical Pathology, Alfred Hospital, Melbourne, Australia
| | - Hamish G MacDougall
- Vestibular Research Laboratory, School of Psychology, University of Sydney, Sydney, Australia
| | - Leslie Roberts
- Department of Neuroscience, St Vincent's Hospital, Melbourne, Australia
| | - Elsdon Storey
- Department of Neuroscience, Monash University, Melbourne, Australia
| | - G Michael Halmagyi
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
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Makino M, Hiwatashi D, Minemura K, Kawaguchi K. Autonomic and sensory ganglionopathy occurring in a patient with fulminant type 1 diabetes mellitus. Pathol Int 2015; 66:102-7. [PMID: 26698638 DOI: 10.1111/pin.12373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 12/01/2015] [Indexed: 12/01/2022]
Abstract
A 63-year-old male with a previous infection was admitted to our hospital because of acute pancreatitis. Although he had no history of diabetes mellitus, laboratory examinations revealed marked hyperglycemia on admission, and intensive insulin treatment was required. After 2 weeks, he developed severe pandysautonomia and sensory impairment, and eventually died from colonic perforation caused by paralytic ileus at 1 year after onset. Autopsy findings showed a complete loss of pancreatic islet beta cells with mild fibrosis of the exocrine pancreas. Neuropathological examination showed myelin loss of the dorsal fasciculus at all levels of the spinal cord and ganglionopathy of the dorsal root and sympathetic truncus, revealing degeneration of ganglion cells and a decrease in their number with the formation of Nageotte nodules. On the basis of this clinicopathological evidence, fulminant type 1 diabetes mellitus (T1DM) and idiopathic immune-mediated autonomic neuropathy were suspected. Here, we suggest a close etiological relationship between both diseases.
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Affiliation(s)
- Mutsuki Makino
- Department of Diagnostic Pathology, Shinonoi General Hospital, Nagano, Japan
| | - Dai Hiwatashi
- Department of Endocrinology, Shinonoi General Hospital, Nagano, Japan
| | - Kesami Minemura
- Department of Endocrinology, Shinonoi General Hospital, Nagano, Japan
| | - Kenji Kawaguchi
- Department of Diagnostic Pathology, Shinonoi General Hospital, Nagano, Japan
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Novak P, Pimentel DA, Sundar B, Moonis M, Qin L, Novak V. Association of Statins with Sensory and Autonomic Ganglionopathy. Front Aging Neurosci 2015; 7:191. [PMID: 26500548 PMCID: PMC4595790 DOI: 10.3389/fnagi.2015.00191] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 09/22/2015] [Indexed: 12/29/2022] Open
Abstract
Objective To examine if statins have an effect on small nerve fibers. Methods This retrospective study evaluated the effect of statins in pure small-fiber neuropathy (SFN). Outcome measures were symptom scales (numbness, tingling, and autonomic symptoms), skin biopsies assessing epidermal nerve fiber density (ENFD), sweat gland nerve fiber density (SGNFD), and quantitative autonomic testing. Results One hundred and sixty participants with pure SFN were identified. Eighty participants (women/men, age ± SD 33/47, 68.1 ± 11.6 years old) were on statins for 53.5 ± 28.7 months to treat dyslipidemia and they were age and gender matched with 80 participants (33/47, 68.1 ± 9.5) that were off statins. ANOVA showed reduced ENFD/SGNFD at the proximal leg in the statin group [(count/mm) 8.3 ± 3.6/51.3 ± 14.2] compared to the off statin group (10.4 ± 3.8, p = 0.0008/56.4 ± 12.7, p = 0.018). There was no difference in ENFD/SGNFD at the distal leg in the statin group (4.9 ± 3.2/39.8 ± 15.7) compared to the off statin group (5.9 ± 3.4, p = 0.067/41.8 ± 15.9, p = 0.426). Statins did not affect symptom scales and the outcome of autonomic testing. Conclusion Statin use is associated with degeneration of sensory and autonomic fibers. The pattern of abnormalities, e.g., degeneration of proximal while sparing of distal fibers, is consistent with a non-length-dependent process with lesions in the dorsal root and the autonomic ganglia. The statin-associated sensory and autonomic ganglionopathy is mild.
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Affiliation(s)
- Peter Novak
- Department of Neurology, University of Massachusetts Medical School , Worcester, MA , USA
| | - Daniela A Pimentel
- Department of Neurology, University of Massachusetts Medical School , Worcester, MA , USA ; Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
| | - Banu Sundar
- Department of Neurology, University of Massachusetts Medical School , Worcester, MA , USA
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Medical School , Worcester, MA , USA
| | - Lan Qin
- Department of Neurology, University of Massachusetts Medical School , Worcester, MA , USA
| | - Vera Novak
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
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Meeusen JW, Haselkorn KE, Fryer JP, Kryzer TJ, Gibbons SJ, Xiao Y, Lennon VA. Gastrointestinal hypomotility with loss of enteric nicotinic acetylcholine receptors: active immunization model in mice. Neurogastroenterol Motil 2013; 25:84-8.e10. [PMID: 23072523 PMCID: PMC3535544 DOI: 10.1111/nmo.12030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Autoimmune gastrointestinal dysmotility (AGID) is a limited form of dysautonomia. The only proven effector to date is IgG specific for ganglionic nicotinic-acetylcholine receptors containing α3 subunits [α3*- nicotinic acetylcholine receptor (nAChR)]. Rabbits immunized with recombinant α3-polypeptide produce α3*-nAChR autoantibodies, and profound AGID ensues. Human and rabbit α3*-nAChR-specific-IgGs induce transient hypomotility when injected into mice. Here, we describe success and problems encountered inducing gastrointestinal hypomotility in mice by active immunization. METHODS We repeatedly injected young adult mice of seven different strains susceptible to autoimmunity (spontaneous diabetes or neural antigen immunization-induced myasthenia gravis or encephalomyelitis) with: (i) α3-polypeptide, intradermally or (ii) live α3*-nAChR-expressing xenogeneic cells, intraperitoneally. We measured serum α3*-nAChR-IgG twice monthly, and terminally assessed blue dye gastrointestinal transit, total small intestinal α3*-nAChR content (radiochemically) and myenteric plexus neuron numbers (immunohistochemically, ileal-jejunal whole-mount preparations). KEY RESULTS Standard cutaneous inoculation with α3-polypeptide was minimally immunogenic, regardless of dose. Intraperitoneally injected live cells were potently immunogenic. Self-reactive α3*-nAChR-IgG was induced only by rodent immunogen; small intestinal transit slowing and enteric α3*-nAChR loss required high serum levels. Ganglionic neurons were not lost. CONCLUSIONS & INFERENCES Autoimmune gastrointestinal dysmotility is inducible in mice by active immunization. Accompanying enteric α3*-nAChR reduction without neuronal death is consistent with an IgG-mediated rather than T cell-mediated pathogenesis, as is improvement of symptoms in patients receiving antibody-depleting therapies.
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Affiliation(s)
- Jeffrey W. Meeusen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - James P. Fryer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Thomas J. Kryzer
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Simon J. Gibbons
- Department of Enteric Neuroscience Program, Mayo Clinic, Rochester, MN
| | - Yingxian Xiao
- Department of Pharmacology and Physiology, Georgetown University School of Medicine, Washington, DC
| | - Vanda A. Lennon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN,Department of Immunology, Mayo Clinic, Rochester, MN,Department of Neurology, Mayo Clinic, Rochester, MN
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