A patient with sensorimotor mononeuritis multiplex had a type II cryoglobulin with an IgM kappa M-protein that appeared to contain monoclonal antiMAG antibodies of the same isotype. A sural nerve biopsy demonstrated necrotizing arteritis and features of both axonal degeneration and demyelination. IgM kappa and C3 deposits were present on the myelin sheath of some residual nerve fibers. The findings suggest that the anti-MAG antibodies contributed to the myelin damage, while cryoprecipitates may have caused the vasculitis and axonal degeneration. 0 1992 John Wiley & Sons, Inc.
Key words: neuropathy anti-MAG antibodies
cryoglobulinemia
vasculitis
MUSCLE & NERVE
demyelination 15:891-898 1992
VASCULlTlC NEUROPATHY IN A PATIENT WITH CRYOGLOBULINEMIA AND ANTI-MAG IGM MONOCLONAL GAMMOPATHY FLORIAN P. THOMAS, MD, ROBERT E. LOVELACE,MD, XIN-SHENG DING, MD, SAUD A. SADIO, MD, GEORGE W. PETTY, MD, WILLIAM H. SHERMAN, MD, NORMAN LATOV, MD, PhD, and ARTHUR P. HAYS, MD
Peripheral neuropathy associated with IgM monoclonal gammopathy may be caused by several different mechanisms. The monoclonal IgM may bind to peripheral nerve antigens, as has been shown for antibodies against myelin associated glycoprotein (MAG) that typically are associated with demyelination and onion bulb alternatively, nerves may be damaged by am loid deposits or infiltration by B-Lymphocytes 133y5 In some cases, the IgM paraproteins are cryoglobulins and precipitate, either alone or in association with polyclonal IgA or IgG,’ and cause axonal degeneration with vascular occlusion or vasculitis. We now report a patient with IgM kappa monoclonal gammopathy, in whom a neuropathy with vasculitis and features of demyelination and axonal degeneration were associated with both cryoglobulinemia and anti-MAG antibody activity.
From the Departments of Pathology, Division of Neuropathology (Drs. Thomas, Ding, and Hays), Neurology (Drs. Thomas, Lovelace, Sadiq, Petty, and Latov), and Internal Medicine (Dr. Sherman), College of Physicians and Surgeons, Columbia University, New York, New York. Drs. Thomas and Sadiq were fellows of the Charles A. Dana Foundation and the Muscular Dystrophy Association. Dr. Thomas is a fellow of the German Cancer Research Society. Address reprint requests to Florian P.Thomas, MD, Clinical Research Institute of Montreal, 110 Pine Avenue West, Montreal, Canada, H2W 1R7. Accepted for publication January 4, 1992. CCC 0148-639)(/92/080891-08 $04.00 0 1992 John Wiley & Sons, Inc.
Neuropathy With Cryoglobulinemia and Anti-MAG Antibodies
Analysis of electrophoretic mobility and light chain type suggested that the anti-MAG paraprotein was a component of the cryoglobulin. CASE REPORT
An 87-year-old woman developed progressive numbness and loss of fine motor control in the fingers over 1 to 2 years, and a burning sensation in the feet, numbness in the legs, and unsteady gait over 6 months. On examination, cranial nerves were normal. Thenar and small hand muscles were atrophic and weak, more on the left than on the right. The leg muscles were atrophic, but not weak. Deep tendon reflexes were absent at the ankles. Plantar responses were flexor. Superficial and vibratory sensation was diminished distally in the arms and legs. Joint position sense was mildly reduced in the feet. Peripheral nerves were not enlarged. Tandem gait was impaired. Quantitative serum immunoglobulins were remarkable for an elevated IgM of 13 g/L (normal 0.5 to 3 g/L) due to an IgM kappa paraprotein. The M-protein had anti-MAG activity as measured by high performance thin layer chromatography.8 The serum also contained a cryoglobulin that consisted of monoclonal IgM kappa and polyclonal IgC. The IgM kappa in the cryoprecipitate was insoluble and could not be tested for anti-MAG activity, but the pchain had the same electrophoretic mobility as the anti-MAG pchain after reduction and alky-
MUSCLE & NERVE
August 1992
891
(Sigma, St. Louis, MO)"" and to the C3d component of human complement (Dako, Carpinteria, CA). Immunofluorescence was performed in 3 sural nerves from patients with chronic neuropathies of unknown etiology as controls. The patient's serum was tested by indirect immunofluorescence for IgM binding to normal nerves." A third portion of the nerve was fixed in 2% paraformaldehyde and 1 % glutaraldehyde in 0.1 mol/I, sodium phosphate buffer, pH 7.3, poststained with 1% osmium tetroxide, and embedded in Epon 812 for preparation of sections for light and electron microscopy. Myelinated fiber diameters and densities were calculated according to Nemni et al.23
lation. The erythrocyte sedimentation rate was 54 mm/h, antinuclear antibodies showed a homogeneous pattern at a dilution of 1:40, the latex fixation test for rheumatoid factor was positive at a dilution of 1:2000. The hematocrit was 0.35 g/L. The cerebrospinal fluid was acellular, with normal glucose, total protein, and IgG content; no oligoclonal bands were found. Normal laboratory values included fasting blood sugar, B,, and folate levels. A bone marrow biopsy revealed 2 lymphoid aggregates with plasmacytoid differentiation and a slight to moderate degree of atypia. Electrophysiological studies and a s u r d nerve biopsy were performed. Treatment with chlorambucil, 4 mg/d, was without benefit. The patient then moved to another state and was lost to follow-up.
'
RESULTS
MATERIALS AND METHODS Electrophysiological Studies. T h e sensory conduction velocity in the right ulnar nerve was slow at 42.3 m/s (lower limit 55 m/s), and the amplitude of the sensory nerve action potential was reduced at 3.0 p,V (lower limit 8 pV) (Table 1). N o sensory potentials could be obtained in the right median and sural nerve. T h e forearm motor conduction velocity in the right median nerve was slow at 37.5 m/s (lower limit 49 m/s), the amplitude of the compound muscle action potential (CMAP) was borderline reduced at 3.2 mV (lower limit 3.8 mV) from elbow stimulation. N o motor response could be obtained by surface recording from the left
Electrophysiological studies were performed with controlled temperature using a TECA electromyograph (TE4 TD20) according to previously established methods and controls."'28
Electrophysiological Studies.
Paraffin-embedded nerve was stained with hematoxylin and eosin and the Mallory connective tissue stain. Another portion of nerve was frozen in liquid nitrogen and cryosections were stained by direct immunofluorescence using fluorescein-isothiocyanate-conjugated antibodies to human IgG, IgM, and IgA Sural Nerve Studies.
Table 1. Electrodiagnostic studies Median
Uinar
Peroneai
L
R
Motor Distal latency Amplitude conduction velocity F-wave latency
R
L
R
L
ED6
120* 32' 37 5* A*
A* A* A* A*
32 11
35" 80 40 1' 32'
A* A* A* A*
489 A*
AT
EDB
AT
59"
A* A* A* A*
60" 125 525 A*
44"
40" A*
Sural Sensory
Distal latency Amplitude Conduction velocity
A* A* A*
A* A* A*
3 6*
3.0* 42 3*
A' A* A*
R
L
A* A* A*
A' A'
A*
The distal latency and the F-wave latency were measured fn mfllfseconds, the motor amphtude /n m/ll/vOlfS,and the sensory amplitude fn m/crovolts A. absent, R, nght, L, left, AT, antenor tibia/, EDB, extensor d/g/torumbrevfs *SigfJiffCantdevfation from normal values *'
''
892
Neuropathy With Cryoglobulinemia and Anti MAG Antibodies
MUSCLE & NERVE
August 1992
FIGURE 1. Arteritis in sural nerve. (A) An epineurial artery shows infiltration of the full thickness of the vessel wall with mononuclear inflammatory cells. The media and internal elastic lamina have been largely destroyed, and necrotic fibrinoid material and nuclear debris are located in the subintimal region. Hematoxylin and eosin stain of paraffin-embedded tissue. (a) The fibrinoid material stains dark red in another level of the same artery. Mallory connective tissue stain. ( x 150).
median nerve. The right ulnar motor conduction velocity and the amplitude of the CMAP were normal. In the left ulnar nerve the motor conduction velocity was slow at 40.1 m/s (lower limit 48 m/s) from above the elbow with focal slowing of 30.8 m/s (lower limit 44 m/s) around the elbow with normal amplitudes of the CMAP and without conduction block. The conduction velocity and the
Neuropathy With Cryoglobulinemia and Anti-MAG Antibodies
amplitude of the CMAP were normal for age in the left peroneal nerve for proximal anterior tibial recording only.. With a concentric needle in the extensor digitorum brevis, no response could be elicited by stimulating the right or left peroneal nerve. With a concentric needle in the right anterior tibial, a conduction velocity of 40 m/s (lower limit 50 m/s) around the neck of the fibula and a
MUSCLE & NERVE
August 1992
893
were of small diameter (Fig. 2). The loss of large myelinated fibers was not focal, but was evenly distributed among the nerve fascicles (Fig. 3). N o myelin debris (myelin ovoids) was found. Isolated thinly myelinated fibers, small onion bulbs, and regenerative clusters of small myelinated fibers were excessive. The number of onion bulbs and regenerative clusters were quantitated using semithin sections at a magnification of 1000 in an area of endoneurium of 0.14 mm2. Onion bulbs were defined as single myelinated nerve fibers that were surrounded by one or more layers of concentrically oriented Schwann cells. Clusters included those with three or more closely apposed myelinated nerve fibers, mostly with thinly myelinated sheaths. The nerve contained 307 onion bulbs/mm2. T h e prevalence of onion bulbs was also determined by electron microscopy at a magnification of 5000. Of a total of 335 myelinated fibers that were analyzed, 43 onion bulbs or 642Imm' were found, an even greater number than by light microscopy because of the higher resolution of the electron microscope (Fig. 4). Onion bulbs of normal individuals have not been quantitated, but they are absent or very sparse in
reduced amplitude of 4.4 mV were recorded. No response could be obtained with surface electrodes from the right posterior tibia1 nerve. By electromyographic examination, no spontaneous activity and reduced recruitment at full effort were found in 9 of 15 muscles in the left arm and leg. N o giant or polyphasic units were present.
By light microscopy of the sural nerve biopsy, one epineural artery, about 300 p,m in diameter, had a markedly disordered wall with concentric, full-thickness infiltration by lymphocytes, histiocytes, and rare polymorphonuclear leukocytes (Fig. 1A). The vessel wall showed focal necrosis consisting of fibrinoid material and a small amount of nuclear debris. The internal elastic lamina was largely destroyed. The lumen of the artery was patent. Patchy fibrinoid necrosis in the subintimal region was confirmed with a Mallory connective tissue stain (Fig. 1B). There was no evidence of microvasculitis or perineuritis. In a semithin section of epoxy-embedded nerve, the myelinated fiber density was 55261mm2, at the lower limit of normal.* A fiber diameter histogram indicated that nearly all of the myelinated fibers
Pathological Findings.
1620
1440
1
\
v1
c4
1260 1080
w
2 tr
o
900 720
1'
I'L
1 .
-
1
540
z
360
0
2 FIBER
4
6
DLAMETER
(km)
8
10
12
14
FIGURE 2. Histogram of myelinated fibers in the patient's biopsy demonstrates loss of virtually all large diameter fibers. There is also a shift to the left in the peak of small myelinated fibers.
894
Neuropathy With Cryoglobulinernia and Anti-MAG Antibodies
MUSCLE & NERVE
August 1992
FIGURE 3. Sural nerve in vasculitic neuropathy with cryoglobulins and anti-MAG paraprotein. There is severe loss of large myelinated nerve fibers. Some remaining nerve fibers exist as regenerative clusters of small myelinated fibers, and many have unusually thin myelin sheaths. Most of these fibers are small onion bulbs, but they are not well shown at this magnification. Semithin section of epoxy-embedded tissue, stained with toluidine blue (x350).
our experience. In semithin sections, the nerve contained 150 regenerative clusters/mm2 (normal
Key words: neuropathy anti-MAG antibodies
cryoglobulinemia
vasculitis
MUSCLE & NERVE
demyelination 15:891-898 1992
VASCULlTlC NEUROPATHY IN A PATIENT WITH CRYOGLOBULINEMIA AND ANTI-MAG IGM MONOCLONAL GAMMOPATHY FLORIAN P. THOMAS, MD, ROBERT E. LOVELACE,MD, XIN-SHENG DING, MD, SAUD A. SADIO, MD, GEORGE W. PETTY, MD, WILLIAM H. SHERMAN, MD, NORMAN LATOV, MD, PhD, and ARTHUR P. HAYS, MD
Peripheral neuropathy associated with IgM monoclonal gammopathy may be caused by several different mechanisms. The monoclonal IgM may bind to peripheral nerve antigens, as has been shown for antibodies against myelin associated glycoprotein (MAG) that typically are associated with demyelination and onion bulb alternatively, nerves may be damaged by am loid deposits or infiltration by B-Lymphocytes 133y5 In some cases, the IgM paraproteins are cryoglobulins and precipitate, either alone or in association with polyclonal IgA or IgG,’ and cause axonal degeneration with vascular occlusion or vasculitis. We now report a patient with IgM kappa monoclonal gammopathy, in whom a neuropathy with vasculitis and features of demyelination and axonal degeneration were associated with both cryoglobulinemia and anti-MAG antibody activity.
From the Departments of Pathology, Division of Neuropathology (Drs. Thomas, Ding, and Hays), Neurology (Drs. Thomas, Lovelace, Sadiq, Petty, and Latov), and Internal Medicine (Dr. Sherman), College of Physicians and Surgeons, Columbia University, New York, New York. Drs. Thomas and Sadiq were fellows of the Charles A. Dana Foundation and the Muscular Dystrophy Association. Dr. Thomas is a fellow of the German Cancer Research Society. Address reprint requests to Florian P.Thomas, MD, Clinical Research Institute of Montreal, 110 Pine Avenue West, Montreal, Canada, H2W 1R7. Accepted for publication January 4, 1992. CCC 0148-639)(/92/080891-08 $04.00 0 1992 John Wiley & Sons, Inc.
Neuropathy With Cryoglobulinemia and Anti-MAG Antibodies
Analysis of electrophoretic mobility and light chain type suggested that the anti-MAG paraprotein was a component of the cryoglobulin. CASE REPORT
An 87-year-old woman developed progressive numbness and loss of fine motor control in the fingers over 1 to 2 years, and a burning sensation in the feet, numbness in the legs, and unsteady gait over 6 months. On examination, cranial nerves were normal. Thenar and small hand muscles were atrophic and weak, more on the left than on the right. The leg muscles were atrophic, but not weak. Deep tendon reflexes were absent at the ankles. Plantar responses were flexor. Superficial and vibratory sensation was diminished distally in the arms and legs. Joint position sense was mildly reduced in the feet. Peripheral nerves were not enlarged. Tandem gait was impaired. Quantitative serum immunoglobulins were remarkable for an elevated IgM of 13 g/L (normal 0.5 to 3 g/L) due to an IgM kappa paraprotein. The M-protein had anti-MAG activity as measured by high performance thin layer chromatography.8 The serum also contained a cryoglobulin that consisted of monoclonal IgM kappa and polyclonal IgC. The IgM kappa in the cryoprecipitate was insoluble and could not be tested for anti-MAG activity, but the pchain had the same electrophoretic mobility as the anti-MAG pchain after reduction and alky-
MUSCLE & NERVE
August 1992
891
(Sigma, St. Louis, MO)"" and to the C3d component of human complement (Dako, Carpinteria, CA). Immunofluorescence was performed in 3 sural nerves from patients with chronic neuropathies of unknown etiology as controls. The patient's serum was tested by indirect immunofluorescence for IgM binding to normal nerves." A third portion of the nerve was fixed in 2% paraformaldehyde and 1 % glutaraldehyde in 0.1 mol/I, sodium phosphate buffer, pH 7.3, poststained with 1% osmium tetroxide, and embedded in Epon 812 for preparation of sections for light and electron microscopy. Myelinated fiber diameters and densities were calculated according to Nemni et al.23
lation. The erythrocyte sedimentation rate was 54 mm/h, antinuclear antibodies showed a homogeneous pattern at a dilution of 1:40, the latex fixation test for rheumatoid factor was positive at a dilution of 1:2000. The hematocrit was 0.35 g/L. The cerebrospinal fluid was acellular, with normal glucose, total protein, and IgG content; no oligoclonal bands were found. Normal laboratory values included fasting blood sugar, B,, and folate levels. A bone marrow biopsy revealed 2 lymphoid aggregates with plasmacytoid differentiation and a slight to moderate degree of atypia. Electrophysiological studies and a s u r d nerve biopsy were performed. Treatment with chlorambucil, 4 mg/d, was without benefit. The patient then moved to another state and was lost to follow-up.
'
RESULTS
MATERIALS AND METHODS Electrophysiological Studies. T h e sensory conduction velocity in the right ulnar nerve was slow at 42.3 m/s (lower limit 55 m/s), and the amplitude of the sensory nerve action potential was reduced at 3.0 p,V (lower limit 8 pV) (Table 1). N o sensory potentials could be obtained in the right median and sural nerve. T h e forearm motor conduction velocity in the right median nerve was slow at 37.5 m/s (lower limit 49 m/s), the amplitude of the compound muscle action potential (CMAP) was borderline reduced at 3.2 mV (lower limit 3.8 mV) from elbow stimulation. N o motor response could be obtained by surface recording from the left
Electrophysiological studies were performed with controlled temperature using a TECA electromyograph (TE4 TD20) according to previously established methods and controls."'28
Electrophysiological Studies.
Paraffin-embedded nerve was stained with hematoxylin and eosin and the Mallory connective tissue stain. Another portion of nerve was frozen in liquid nitrogen and cryosections were stained by direct immunofluorescence using fluorescein-isothiocyanate-conjugated antibodies to human IgG, IgM, and IgA Sural Nerve Studies.
Table 1. Electrodiagnostic studies Median
Uinar
Peroneai
L
R
Motor Distal latency Amplitude conduction velocity F-wave latency
R
L
R
L
ED6
120* 32' 37 5* A*
A* A* A* A*
32 11
35" 80 40 1' 32'
A* A* A* A*
489 A*
AT
EDB
AT
59"
A* A* A* A*
60" 125 525 A*
44"
40" A*
Sural Sensory
Distal latency Amplitude Conduction velocity
A* A* A*
A* A* A*
3 6*
3.0* 42 3*
A' A* A*
R
L
A* A* A*
A' A'
A*
The distal latency and the F-wave latency were measured fn mfllfseconds, the motor amphtude /n m/ll/vOlfS,and the sensory amplitude fn m/crovolts A. absent, R, nght, L, left, AT, antenor tibia/, EDB, extensor d/g/torumbrevfs *SigfJiffCantdevfation from normal values *'
''
892
Neuropathy With Cryoglobulinemia and Anti MAG Antibodies
MUSCLE & NERVE
August 1992
FIGURE 1. Arteritis in sural nerve. (A) An epineurial artery shows infiltration of the full thickness of the vessel wall with mononuclear inflammatory cells. The media and internal elastic lamina have been largely destroyed, and necrotic fibrinoid material and nuclear debris are located in the subintimal region. Hematoxylin and eosin stain of paraffin-embedded tissue. (a) The fibrinoid material stains dark red in another level of the same artery. Mallory connective tissue stain. ( x 150).
median nerve. The right ulnar motor conduction velocity and the amplitude of the CMAP were normal. In the left ulnar nerve the motor conduction velocity was slow at 40.1 m/s (lower limit 48 m/s) from above the elbow with focal slowing of 30.8 m/s (lower limit 44 m/s) around the elbow with normal amplitudes of the CMAP and without conduction block. The conduction velocity and the
Neuropathy With Cryoglobulinemia and Anti-MAG Antibodies
amplitude of the CMAP were normal for age in the left peroneal nerve for proximal anterior tibial recording only.. With a concentric needle in the extensor digitorum brevis, no response could be elicited by stimulating the right or left peroneal nerve. With a concentric needle in the right anterior tibial, a conduction velocity of 40 m/s (lower limit 50 m/s) around the neck of the fibula and a
MUSCLE & NERVE
August 1992
893
were of small diameter (Fig. 2). The loss of large myelinated fibers was not focal, but was evenly distributed among the nerve fascicles (Fig. 3). N o myelin debris (myelin ovoids) was found. Isolated thinly myelinated fibers, small onion bulbs, and regenerative clusters of small myelinated fibers were excessive. The number of onion bulbs and regenerative clusters were quantitated using semithin sections at a magnification of 1000 in an area of endoneurium of 0.14 mm2. Onion bulbs were defined as single myelinated nerve fibers that were surrounded by one or more layers of concentrically oriented Schwann cells. Clusters included those with three or more closely apposed myelinated nerve fibers, mostly with thinly myelinated sheaths. The nerve contained 307 onion bulbs/mm2. T h e prevalence of onion bulbs was also determined by electron microscopy at a magnification of 5000. Of a total of 335 myelinated fibers that were analyzed, 43 onion bulbs or 642Imm' were found, an even greater number than by light microscopy because of the higher resolution of the electron microscope (Fig. 4). Onion bulbs of normal individuals have not been quantitated, but they are absent or very sparse in
reduced amplitude of 4.4 mV were recorded. No response could be obtained with surface electrodes from the right posterior tibia1 nerve. By electromyographic examination, no spontaneous activity and reduced recruitment at full effort were found in 9 of 15 muscles in the left arm and leg. N o giant or polyphasic units were present.
By light microscopy of the sural nerve biopsy, one epineural artery, about 300 p,m in diameter, had a markedly disordered wall with concentric, full-thickness infiltration by lymphocytes, histiocytes, and rare polymorphonuclear leukocytes (Fig. 1A). The vessel wall showed focal necrosis consisting of fibrinoid material and a small amount of nuclear debris. The internal elastic lamina was largely destroyed. The lumen of the artery was patent. Patchy fibrinoid necrosis in the subintimal region was confirmed with a Mallory connective tissue stain (Fig. 1B). There was no evidence of microvasculitis or perineuritis. In a semithin section of epoxy-embedded nerve, the myelinated fiber density was 55261mm2, at the lower limit of normal.* A fiber diameter histogram indicated that nearly all of the myelinated fibers
Pathological Findings.
1620
1440
1
\
v1
c4
1260 1080
w
2 tr
o
900 720
1'
I'L
1 .
-
1
540
z
360
0
2 FIBER
4
6
DLAMETER
(km)
8
10
12
14
FIGURE 2. Histogram of myelinated fibers in the patient's biopsy demonstrates loss of virtually all large diameter fibers. There is also a shift to the left in the peak of small myelinated fibers.
894
Neuropathy With Cryoglobulinernia and Anti-MAG Antibodies
MUSCLE & NERVE
August 1992
FIGURE 3. Sural nerve in vasculitic neuropathy with cryoglobulins and anti-MAG paraprotein. There is severe loss of large myelinated nerve fibers. Some remaining nerve fibers exist as regenerative clusters of small myelinated fibers, and many have unusually thin myelin sheaths. Most of these fibers are small onion bulbs, but they are not well shown at this magnification. Semithin section of epoxy-embedded tissue, stained with toluidine blue (x350).
our experience. In semithin sections, the nerve contained 150 regenerative clusters/mm2 (normal
