|Year : 2020 | Volume
| Issue : 2 | Page : 130-134
Clinical, electrophysiological, and histopathological profile of biopsy-proven vasculitic neuropathy
Suchitra Deolalikar1, Preethi A M. Paul2, Vineeth Jaison3, Jayshree Nandi4, Deepti Arora3, Jeyaraj D Pandian3, Mahesh P Kate3
1 Department of Physiology, Christian Medical College, Ludhiana, Punjab, India
2 Department of Pathology, Christian Medical College, Ludhiana, Punjab, India
3 Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
4 Department of Community Medicine, Christian Medical College, Ludhiana, Punjab, India
|Date of Submission||20-Mar-2019|
|Date of Decision||16-Apr-2019|
|Date of Acceptance||25-Jun-2019|
|Date of Web Publication||8-Oct-2020|
Mahesh P Kate
Department of Neurology, Christian Medical College, Brown Road, Ludhiana - 141 008, Punjab
Source of Support: None, Conflict of Interest: None
Background: Vasculitic neuropathies are an uncommon heterogeneous group of nerve disorders characterized by inflammation of the vasa nervorum, which may be either systemic vasculitic neuropathy (SVN) or non-SVN (NSVN). Settings and Design: This is a retrospective, observational study. Materials and Methods: Nerve biopsy-proven cases of vasculitic neuropathy (VN) from January 2011 to December 2017 were included in the study. Results: Twenty-five percent (40/156) patients had vasculitis on biopsy, 62.5% were male and the mean age was 52.8 ± 14.9 years. The median (interquartile range) duration of symptoms before diagnosis was 75 (345) days. Thirty (75%) patients had NSVN and 10 (25%) patients had SVN. The clinical pattern of peripheral nervous system involvement was as follows: 20 (50%) had polyneuropathy, 13 (32.5%) had mononeuritis multiplex, and 7 (32.5%) had polyradiculoneuropathy. Twenty-three (57.5%) patients received immunomodulatory therapy. Conclusion: VN has a wide spectrum of clinical presentation. High index of suspicion followed by nerve biopsy is needed for diagnosis. Early treatment may improve prognosis in this group of patients.
Keywords: Nerve biopsy, polyneuropathy, vasculitic neuropathy
|How to cite this article:|
Deolalikar S, M. Paul PA, Jaison V, Nandi J, Arora D, Pandian JD, Kate MP. Clinical, electrophysiological, and histopathological profile of biopsy-proven vasculitic neuropathy. CHRISMED J Health Res 2020;7:130-4
|How to cite this URL:|
Deolalikar S, M. Paul PA, Jaison V, Nandi J, Arora D, Pandian JD, Kate MP. Clinical, electrophysiological, and histopathological profile of biopsy-proven vasculitic neuropathy. CHRISMED J Health Res [serial online] 2020 [cited 2020 Oct 29];7:130-4. Available from: https://www.cjhr.org/text.asp?2020/7/2/130/297577
| Introduction|| |
Vasculitic neuropathies are uncommon heterogeneous group of peripheral nerve disorders characterized by chronic intramural inflammation of the vasa nervorum. Vasculitic neuropathy (VN) has a wide spectrum of clinical presentation. They can be broadly classified as systemic vasculitic neuropathy (SVN) and nonSVN (NSVN). Systemic vasculitis with neuropathy is a disabling illness with a 5-year survival of 37%. It may occur due to autoimmune diseases or infectious diseases.
Neuropathy due to vasculitis without manifestations of disorders in other systems was first reported by Kernohan and Woltman in 1938. Over the years, NSVN has emerged as a distinct clinical entity, thought to account for 25%–33% of cases of VN. The age of onset is in the middle and elderly age group with relatively equal distribution between the sexes. Constitutional symptoms may occur, including weight loss, fever, myalgia, and arthralgia. Laboratory testing is within the normal limits except elevated erythrocyte sedimentation rate (ESR). NSVN can be diagnosed histopathologically with the help of a nerve biopsy having diagnostic sensitivity of 50%–60%.
In the workup of neuropathy, nerve biopsies are seldom performed; hence, VN remains an under-recognized condition. The distinctive feature of all VN is inflammation of the epineural, perineural, and endoneurial arteries, causing thrombosis and occlusion. There are recruitment and accumulation of T-lymphocytes and macrophages in the inflammatory zone. This leads to ischemic damage and axonal neuropathy. Patients with evidence of active lesions with fibrinoid necrosis, acute thrombosis, and leukocytolclasis need early and aggressive management. Patients showing improvement without new deficits may be observed without treatment. Despite recent guidelines on VN, it is difficult to diagnose and initiate early treatment in patients. There is need of more data from different parts of the world to develop clinical and laboratory predictors for rapid diagnosis and prognosis. We aim to characterize the clinical spectrum, electrophysiological, and histopathological features of VN.
| Materials and Methods|| |
This is a retrospective, observational study. The study was approved by the Institutional Research Committee. Biopsy-proven cases of VN from January 2011 to December 2017 were included in the study. In a structured case record form clinical, electrophysiology, pathological details, and treatments details were recorded.
On a structured case record form all demographic and clinical details were abstracted. This included age, sex, duration of illness (days), symptoms at onset, clinical diagnosis, and examination findings (motor power and sensory pattern of involvement). Laboratory results and history were also reviewed to differentiate between NSVN and SVN. SVN was defined as the presence of neuropathy and associated clinical or laboratory features satisfying the diagnostic criteria for any named vasculitis according to the Chapel Hill Consensus Conference.
Nerve conduction studies were performed (using Model no. NE -132 B Nihon Kohden corporation NCV/EMG isolation unit, model SM-930 AK SN02659. Made in Japan) in the Neurology Laboratory, Department of Neurology. The neurological protocol included motor nerve studies on ulnar, median, tibial, and peroneal nerves on both sides; as per the discretion of the clinician, additional motor studies were performed according to clinical deficits. Sensory nerve conduction studies included ulnar, median, sural nerves on both sides; as per the discretion of the clinician, additional sensory studies were performed according to clinical deficits. In addition, “F Wave” studies were done on ulnar, median, tibial and peroneal nerves. The H-reflex was also studied. All nerve conduction studies were reviewed by Neurologist (VJ and MK) and Physiologist (SD).
Nerve biopsy was done in patients with a suspected diagnosis of VN or for atypical presentation or to decide long-term therapy in patients with demyelinating neuropathy according to the institutional protocol. Sural nerve biopsies were performed in all patients after informed consent and under all aseptic precautions. Biopsies of peripheral nerve were fixed in 10% neutral buffered formalin. Entire tissue was processed with transverse and longitudinal sections for routine histopathological processing and paraffin embedding. Serial sections were taken at 4-μ thickness and stained with hematoxylin-eosin and solochrome cyanine for myelin. In addition, Congo red stain and modified Zeihl-Neelsen stain were carried out for detecting amyloid and lepra bacilli, respectively. Immunohistochemistry by indirect immune peroxidase method was carried out using routine antibody protocols for leukocyte common antigen (LCA/CD45) for leukocytes and neurofilament for axons in select cases.
All nerve biopsies were systematically reviewed by Pathologist (PP), and findings were recorded. Histopathological diagnosis of vasculitis was confirmed based on the current established pathological criteria by Collins et al., 2010. Biopsies were diagnosed with having pathologically “definite” or “probable” VN. Pathologically, definite vasculitis cases were further subclassified as having “active lesion” or “chronic lesion with the signs of healing/repair.”
All statistical analysis was performed on SPSS (Version 20, IBM, Armonk, USA). The patients were classified as systemic and nonsystemic vasculitis. Descriptive analysis was performed, and variables were presented as mean, median, the standard of deviation interquartile range (IQR), and percentages. Nominal variables including sex, patterns of neuropathy, biopsy findings, and diagnosis were analyzed using the Chi-square test, and continuous variables including age and duration of illness were assessed with Student's t-test.
| Results|| |
A total number of nerve biopsies performed and analyzed during January 2011–December 2017 was 156. Forty (25.6%) patients were diagnosed to have vasculitis on nerve biopsy. The mean age in years was 52.8 ± 14.9, and 25 (62.5%) were males. The median (IQR) duration of symptoms before diagnosis was 75 (345) days. Thirty (75%) patients had NSVN, and 10 (25%) patients had SVN. SVN was associated with rheumatoid arthritis 5 (50%), Churg–Strauss syndrome 4 (40%), and cryoglobulinemia 1 (10%). In patients with NSVN, the presenting symptoms were weakness of lower limb 12 (40%), weakness of upper limb 2 (6.7%), numbness of limbs 11 (36.7%), weakness of both upper and lower limbs 2 (6.7%), generalized weakness 1 (3.3%), recurrent ulcers of the right hand 1 (3.3%), and burning sensation in feet 1 (3.3%). The clinical pattern of peripheral nervous system involvement was as follows: 20 (50%) had polyneuropathy (symmetric or asymmetric), 13 (32.5%) had mononeuritis multiplex, and 7 (32.5%) had polyradiculoneuropathy [Table 1]. Nerve conduction studies of 26 patients were available for review. Sixteen patients had axonal, 6 had demyelinating, and 4 had both axonal and demyelinating involvement.
Based on Peripheral Nerve Society guidelines criteria 34 (85%) were classified as definite vasculitis, and 6 (15%) were classified as probable vasculitis [Figure 1]. In patients with NSVN, 83.3% (25/30) had definite vasculitis; six patients had active lesions and 19 patients had chronic lesions. In patients with NSVN 50% (15/30) had both perineural and endoneurial vessels involved, and 50% (15/30) had only perineural vessels involved. The cellular infiltrates in biopsy was isolated lymphocytic or neutrophilic in 56.7% (17/30); in 30% (9/30), it was a combination of lymphocytes, neutrophils, histiocytes, or eosinophils. Other findings included fibrinoid necrosis 6.7% (2/30), leukocytoclasis 13.3% (4/30), thrombotic occlusion 20% (6/30), vessel wall thickening 63.3% (19/30), endothelial swelling 66.7% (20/30), luminal narrowing 63.3% (19/30), and demyelination 66.7% (20/30).
|Figure 1: (a) Active vasculitis - leukocytoclasis (black arrows), dense mixed transmural inflammatory infiltrate of neutrophils, lymphocytes and histiocytes, with marked luminal narrowing and endothelial swelling. (b) Active vasculitis - fibrinoid necrosis (asterix). (c) Chronic lesion - transmural vasculitis with predominant lymphocytic infiltrate. (d) Probable vasculitis - thickening of perineurial vessel wall with luminal narrowing (red arrow), mild perivascular lymphocytic infiltrate, H and E, ×400. (e) Myelin stain - moderate demyelination, ×400. (f) Neurofilament immunohistochemistry for axons - marked axonal loss, ×400|
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In patients with SVN, 90% (9/10) had definite vasculitis, 6 had active lesions and 3 had chronic lesions. Eighty percent (8/10) had isolated perineural vessel involved and remaining two patients had both perineural and endoneurial involvement. The cellular infiltrate in biopsy was isolated lymphocytic in 10% (1/10), it was a combination of lymphocytes, histiocytes, neutrophils, and eosinophils in 72.7% (9/10). Other findings included fibrinoid necrosis 40% (4/10), leukocytoclasis 60% (6/10), thrombotic occlusion 20% (2/10), vessel wall thickening 100% (10/10), endothelial swelling 90% (9/10), luminal narrowing 70% (7/10), and demyelination 70% (7/10). Perineural infiltrates (P = 0.09), fibrinoid necrosis (P = 0.01), leukocytoclasis (P = 0.003), and vessel wall thickening (0.02), was more commonly seen in SVN compared to NSVN. There was no difference in the other histopathological parameters.
A total of 23 out of 40 patients received immunomodulatory therapy. The therapy included prednisolone 12 (52.2%), prednisolone plus azathioprine 8 (34.8%), prednisolone plus intravenous cyclophosphamide 2 (8.7%), and azathioprine plus cyclophosphamide 1 (4.3%). Follow-up data were available only in 15 patients. Four patients expired, of which 3 patients in NSVN and 1 patient in the SVN group.
| Discussion|| |
In our study, a higher proportion of patients (25.6%) had vasculitis on nerve biopsies. The spectrum of presentation was wide and diagnosis was delayed. On histopathology, fibrinoid necrosis, leukocytoclasis, perineural infiltrates, and vessel wall thickening was more common in SVN compared to NSVN.
Asymmetric limb weakness is the most common presentation followed by polyneuropathy pattern in patients with VN [Table 2]. These presentations are seen in Hansen's disease and diabetic neuropathy as well. It is difficult to confirm a diagnosis of VN clinically, however stepwise progression, presence of serum antimyeloperoxidase antibody, ESR >100 mm/h, antineutrophilic cytoplasmic antibody, and rheumatoid factor seropositivity may suggest VN., High-resolution ultrasonography may show an enlargement in the longitudinal diameter of superficial peroneal nerve. A normal or primarily demyelinating nerve conduction study points against VN. In our study, 6 patients had primarily demyelinating nerve conduction studies. One patient had Churg–Strauss disease and presented with mononeuritis, but the remaining five patients had NSVN. The diagnosis did indeed come as unexpected. Hence, nerve biopsy should be considered in patients with suspected VN; however, the yield may be low (20%), and in unsuspected patients, it is only 3%. The yield of diagnosis increases by 15%–23% with a combined nerve and muscle biopsy., Recent Brighton Collaboration Case definition allows a level 3 diagnosis (minimum acceptable evidence) in resource poor settings where nerve biopsy cannot be done. Electrodiagnostic evidence of peripheral neuropathy and a clinical presentation that is typical for VN (multifocal or asymmetric, involving sensory or sensory-motor nerves, lower limb-predominant, painful and with one or more acute attacks) may suggest a clinically probable VN.
In our study, 58% of patients received immunomodulatory therapy. Patients with persistent or progressive disability, recurrence, and active vasculitis on nerve biopsy should be considered for treatment. The response of VN to steroids and other immunomodulatory therapies is variable. Treatment with combined steroids and cyclophosphamide, azathioprine, or methotrexate is recommended if there is no response. Good outcomes have been reported in VN with adequate therapy in previous studies, with 5-year survival rates up to 87%.
| Conclusion|| |
VN is an under-recognized cause of neuropathy. Nerve biopsy is needed for diagnosis. Early treatment in patients with recurrence and active vasculitis on biopsy may be associated with good prognosis.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]