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Expert Opinion on Drug Safety Apr 2020: Immune checkpoint inhibitors (ICI) are associated with a wide spectrum of neurologic immune-related adverse events (irAEs) including meningo-encephalitis, myasthenia... (Review)
Review
: Immune checkpoint inhibitors (ICI) are associated with a wide spectrum of neurologic immune-related adverse events (irAEs) including meningo-encephalitis, myasthenia gravis and various neuropathies. Although relatively rare, they often present significant diagnostic complexity and may be under-recognized. Permanent neurologic deficits and/or fatality have been described but improvement is noted in most cases with ICI discontinuation and immunosuppressive therapy.: This review highlights the most frequently reported ICI-associated neurologic toxicities with a particular focus on those that may be more severe and/or fatal. Data from case series and pharmacovigilance studies is leveraged to provide an overview of associated clinical features, expected outcomes and appropriate management. Various immunobiologic triggers have been proposed to explain why certain patients might develop neurologic irAEs and are also briefly discussed.: All providers who care for patients with cancer should be made aware of common neurologic irAEs and able to recognize when prompt evaluation and consultation with appropriate specialists are indicated. Symptoms suggestive of encephalitis, myasthenia-gravis or an acute polyradiculopathy such as Guillain-Barre Syndrome (GBS) in patients exposed to these agents warrant immediate attention with a low threshold for hospitalization to expedite work-up and monitor for severe and/or life-threatening manifestations.
Topics: Animals; Antineoplastic Agents, Immunological; Humans; Immune Checkpoint Inhibitors; Neoplasms; Neurotoxicity Syndromes
PubMed: 32126176
DOI: 10.1080/14740338.2020.1738382 -
The Orthopedic Clinics of North America Apr 2022Cauda equina syndrome (CES) involves compression of some or all of the lumbar and sacral peripheral nerve roots. However, there is a lack of consensus in the literature... (Review)
Review
Cauda equina syndrome (CES) involves compression of some or all of the lumbar and sacral peripheral nerve roots. However, there is a lack of consensus in the literature regarding the exact diagnosis criteria in this patient population. Much of the pathophysiology has been studied regarding the onset of this condition; however, the long-term effects are not able to be accurately predicted at this time. Recent literature has associated timing to surgical decompression, severity of symptoms at time of onset, and involvement of bladder dysfunction as prognostic indicators of CES.
Topics: Cauda Equina; Cauda Equina Syndrome; Decompression, Surgical; Humans; Polyradiculopathy; Prognosis
PubMed: 35365269
DOI: 10.1016/j.ocl.2021.11.010 -
International Orthopaedics Feb 2022International uniformity of definition and classification are crucial for diagnosis and management of cauda equina syndrome (CES). They are also useful for clinicians... (Review)
Review
PURPOSE
International uniformity of definition and classification are crucial for diagnosis and management of cauda equina syndrome (CES). They are also useful for clinicians when discussing CES with patients and relatives, and for medicolegal purposes.
METHODS
We reviewed published literature using PubMed on definition and classification of cauda equina syndrome since 2000 (21 years). Using the search terms 'cauda equina' and 'definition' or 'classification', we found and reviewed 212 papers.
RESULTS
There were 17 different definitions of CES used in the literature. There were three well-defined methods of classification of CES. The two-stage system of incomplete CES (CESI) versus CES with retention (CESR) is the most commonly used classification, and has prognostic value although the details of this continue to be debated.
CONCLUSION
We used the existing literature to propose a clear definition of CES. We also drew on peer-reviewed published literature that has helped to amplify and expand the CESI/CESR dichotomy, adding categories that are both less severe than CESI, and more severe than CESR, and we propose clear definitions in a table form to assist current and future discussion and management of CES.
Topics: Cauda Equina Syndrome; Humans; Polyradiculopathy; Prognosis
PubMed: 34862914
DOI: 10.1007/s00264-021-05273-1 -
Clinical Autonomic Research : Official... Jun 2019Guillain-Barré syndrome (GBS), an inflammatory, usually demyelinating polyradiculopathy, is characterized by ascending symmetrical limb weakness, sensory disturbances,... (Review)
Review
BACKGROUND
Guillain-Barré syndrome (GBS), an inflammatory, usually demyelinating polyradiculopathy, is characterized by ascending symmetrical limb weakness, sensory disturbances, and absent or reduced deep tendon reflexes. There is extensive literature suggesting that GBS is associated with autonomic dysfunction in up to two-thirds of patients. However, it is interesting that there is still no consensus amongst medical professionals regarding whether GBS patients should be routinely screened for autonomic nervous system (ANS) neuropathy. This is an important issue, as the mortality rate from presumed ANS abnormalities now exceeds that of respiratory failure. Given the long interval since this literature was last comprehensively reviewed, an update on this topic is warranted.
METHODS
A PubMed search yielded 193 results with the terms "GBS or Guillain-Barré syndrome and autonomic symptoms" and 127 results with the terms "GBS or Guillain-Barré syndrome and dysautonomia."
RESULTS
This review will summarize the current literature involving GBS and autonomic dysfunction in terms of presentation, management, and a brief discussion of prognosis. We also examine prospective approaches that may be helpful and update a proposed management plan.
Topics: Autonomic Nervous System; Guillain-Barre Syndrome; Humans; Immunotherapy
PubMed: 30019292
DOI: 10.1007/s10286-018-0542-y -
JAMA Neurology Dec 2015Peripheral neuropathy is a prevalent condition that usually warrants a thorough history and examination but has limited diagnostic evaluation. However, rare... (Review)
Review
IMPORTANCE
Peripheral neuropathy is a prevalent condition that usually warrants a thorough history and examination but has limited diagnostic evaluation. However, rare localizations of peripheral neuropathy often require more extensive diagnostic testing and different treatments.
OBJECTIVE
To describe rare localizations of peripheral neuropathy, including the appropriate diagnostic evaluation and available treatments.
EVIDENCE REVIEW
References were identified from PubMed searches conducted on May 29, 2015, with an emphasis on systematic reviews and randomized clinical trials. Articles were also identified through the use of the authors' own files. Search terms included common rare neuropathy localizations and their causes, as well as epidemiology, pathophysiology, diagnosis, and treatment.
FINDINGS
Diffuse, nonlength-dependent neuropathies, multiple mononeuropathies, polyradiculopathies, plexopathies, and radiculoplexus neuropathies are rare peripheral neuropathy localizations that often require extensive diagnostic testing. Atypical neuropathy features, such as acute/subacute onset, asymmetry, and/or motor predominant signs, are frequently present. The most common diffuse, nonlength-dependent neuropathies are Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and amyotrophic lateral sclerosis. Effective disease-modifying therapies exist for many diffuse, nonlength-dependent neuropathies including Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy, and some paraprotein-associated demyelinating neuropathies. Vasculitic neuropathy (multiple mononeuropathy) also has efficacious treatment options, but definitive evidence of a treatment effect for IgM anti-MAG neuropathy and diabetic amyotrophy (radiculoplexus neuropathy) is lacking.
CONCLUSIONS AND RELEVANCE
Recognition of rare localizations of peripheral neuropathy is essential given the implications for diagnostic testing and treatment. Electrodiagnostic studies are an important early step in the diagnostic evaluation and provide information on the localization and pathophysiology of nerve injury.
Topics: Disease Management; Humans; Peripheral Nervous System Diseases; Treatment Outcome
PubMed: 26437251
DOI: 10.1001/jamaneurol.2015.2347 -
Neuroimaging Clinics of North America May 2015Spinal infections are a spectrum of disease comprising spondylitis, diskitis, spondylodiskitis, pyogenic facet arthropathy, epidural infections, meningitis,... (Review)
Review
Spinal infections are a spectrum of disease comprising spondylitis, diskitis, spondylodiskitis, pyogenic facet arthropathy, epidural infections, meningitis, polyradiculopathy, and myelitis. Inflammation can be caused by pyogenic, granulomatous, autoimmune, idiopathic, and iatrogenic conditions. In an era of immune suppression, tuberculosis, and HIV epidemic, together with worldwide socioeconomic fluctuations, spinal infections are increasing. Despite advanced diagnostic technology, diagnosis of this entity and differentiation from degenerative disease, noninfective inflammatory lesions, and spinal neoplasms are difficult. Radiological evaluations play an important role, with contrast-enhanced MR imaging the modality of choice in diagnosis, evaluation, treatment planning, interventional treatment, and treatment monitoring of spinal infections.
Topics: Epidural Abscess; Humans; Magnetic Resonance Imaging; Spinal Diseases; Spine; Spondylitis
PubMed: 25952173
DOI: 10.1016/j.nic.2015.01.003 -
Deutsches Arzteblatt International Nov 2018The new German S3 guideline on Lyme neuroborreliosis is intended to provide physicians with scientifically based information and recommendations on the diagnosis and...
BACKGROUND
The new German S3 guideline on Lyme neuroborreliosis is intended to provide physicians with scientifically based information and recommendations on the diagnosis and treatment of this disease.
METHODS
The scientific literature was systematically searched and the retrieved publications were assessed at the German Cochrane Center (Deutsches Cochrane Zentrum) in Freiburg in the 12 months beginning in March 2014. In addition to the main search terms "Lyme disease," "neuroborreliosis," "Borrelia," and "Bannwarth," 28 further terms relating to neurological manifestations of the disease were used for the search in the Medline and Embase databases and in the Cochrane Central Register of Controlled Trials.
RESULTS
In the treatment of early Lyme neuroborreliosis, orally administered doxycycline is well tolerated, and its efficacy is equivalent to that of intravenously administered beta-lactam antibiotics (penicillin G, ceftriaxone, and cefotaxime) (relative risk [RR]: 0.98, 95% confidence interval [CI]: [0.68; 1.42], P = 0.93). 14 days of treatment suffice for early Lyme neuroborreliosis, and 14-21 days of treatment usually suffice for late (chronic) Lyme neuroborreliosis.
CONCLUSION
Lyme neuroborreliosis has a favorable prognosis if treated early. The long-term administration of antibiotics over many weeks or even months for putative chronic Lyme neuroborreliosis with nonspecific symptoms yields no additional benefit and carries the risk of serious adverse effects.
Topics: Anti-Bacterial Agents; Borrelia; Doxycycline; Humans; Lyme Neuroborreliosis; Polyradiculopathy; Prognosis; Treatment Outcome
PubMed: 30573008
DOI: 10.3238/arztebl.2018.0751 -
Continuum (Minneapolis, Minn.) Apr 2018Conditions that affect the cauda equina are a diverse group of disorders that require timely recognition and management. This article reviews cauda equina anatomy, the... (Review)
Review
PURPOSE OF REVIEW
Conditions that affect the cauda equina are a diverse group of disorders that require timely recognition and management. This article reviews cauda equina anatomy, the diagnostic approach to disorders of the cauda equina, features of cauda equina syndrome, and diskogenic and nondiskogenic disorders of the cauda equina.
RECENT FINDINGS
Establishing clinical criteria for cauda equina syndrome has been a focus of a number of reviews, although the clinician must maintain a low threshold for emergent imaging in cases of suspected cauda equina syndrome because of the suboptimal reliability of various signs and symptoms in identifying this condition clinically. The timing of surgical intervention for compressive causes of cauda equina dysfunction remains a point of contention, although urgent decompression remains standard practice. A recent review that focused on outcomes in patients with cauda equina compression who underwent surgical decompression identified significant residual deficits in patients despite appropriate and timely intervention. Autoimmune conditions targeting the cauda equina have been increasingly recognized, including chronic immune sensory polyradiculopathy and chronic immune sensorimotor polyradiculopathy.
SUMMARY
Disorders that affect the cauda equina require thoughtful and timely clinical examination and diagnostic testing to establish a definitive cause and an appropriate treatment approach.
Topics: Autoimmune Diseases; Cauda Equina; Decompression; Humans; Polyradiculopathy; Time Factors
PubMed: 29613901
DOI: 10.1212/CON.0000000000000584