Cutaneous biomarkers of therapeutic efficacy in early treatment of hereditary ATTR amyloid polyneuropathy with tafamidis.

BACKGROUND: ATTR (ATTRv) amyloidosis neuropathy is characterized by progressive sensorimotor and autonomic nerve degeneration secondary to amyloid deposition caused by a misfolded transthyretin protein (TTR). Small nerve fiber neuropathy is an early clinical manifestation of this disease resulting from the dysfunction of the Aδ and C small nerve fibers. Tafamidis, a selective TTR stabilizer, has proven its efficacy in the earlier stages of hATTR. OBJECTIVES: To evaluate the clinical course and utility of cutaneous pathological biomarkers in patients with ATTR amyloidosis treated with tafamidis compared to control patients. METHODS: Forty patients diagnosed with early stages of ATTRv amyloidosis (polyneuropathy disability [PND] scores 0-II) underwent small and large nerve fiber neurological evaluations, and annual skin biopsies for intraepidermal nerve fiber density (IENFD) and amyloid deposition index (ADI) estimation. Thirty patients were allocated to receive tafamidis, and 10 patients served as controls. Tafamidis pharmacokinetics analysis was performed in patients who received the treatment. RESULTS: At baseline, 12% of patients in stage PND 0 and 28% in PND I displayed small nerve fiber denervation in the distal thigh, whereas 23% and 38%, respectively, in the distal leg. Similarly, 72% and 84% had amyloid deposition in the distal thigh and 56% and 69% in the distal leg. Following 1 year of treatment, the tafamidis group showed significant clinical improvement compared to the control group, revealed by the following mean differences (1) -9.3 versus -4 points (p = <.00) in the patient's neuropathy total symptom score 6 (NTSS-6) questionnaire, (2) -2.5 versus +2.8 points (p = <.00) in the Utah Early Neuropathy Score (UENS), and (3) +1.2°C versus -0.6 (p = .01) in cold detection thresholds. Among the patients who received tafamidis, 65% had stable or increased IENFD in their distal thigh and 27% in the distal leg. In contrast, all patients in the control group underwent denervation. The ADI either decreased or remained constant in 31% of the biopsies in the distal thigh and in 24% of the biopsies in the distal leg of the tafamidis-treated patients, whereas it rose across all the biopsies in the control group. At the 4-year follow-up, the tafamidis group continued to display less denervation in the distal thigh (mean difference [MD] of -3.0 vs. -9.3 fibers/mm) and the distal leg (mean difference [MD] -4.9 vs. -8.6 fibers/mm). ADI in tafamidis-treated patients was also lower in the distal thigh (10 vs. 30 amyloid/mm2) and the distal leg (23 vs. 40 amyloid/mm2) compared to control patients. Plasma tafamidis concentrations were higher in patients with IENFD improvement and in patients with reduced amyloid deposition. Patients without amyloid deposition in the distal leg at baseline displayed delayed disease progression at 4 years. CONCLUSIONS: Cutaneous IENFD and amyloid deposition assessments in the skin of the distal thigh and distal leg are valuable biomarkers for early diagnosis of ATTR amyloidosis and for measuring the progression of small nerve fiber neuropathy. Early treatment with tafamidis slows the clinical progression of the disease, skin denervation, and amyloid deposition in the skin. Higher plasma concentrations of tafamidis are associated with better disease outcomes, suggesting that increasing the drug dose could achieve better plasma concentrations and response rates. This study describes the longest small nerve fiber neuropathy therapeutic trial with tafamidis and is the first to report small fiber symptoms, function, and structural assessments as outcomes.

Lactate dehydrogenase as a prognostic marker in neoplastic meningitis.

This study aimed to establish the prognostic utility of lactate dehydrogenase (LDH) levels in the cerebrospinal fluid (CSF) of patients with neoplastic meningitis (NM). Patients with a confirmed diagnosis of NM at a cancer referral center were included. Data on demographic and oncological background, clinical symptoms, diagnostic tests, treatment, and survival were analyzed. In total, 119 patients were included, 74% of whom were females. The mean age was 44.2 years at the time of cancer diagnosis and 46.6 years at the time between NM diagnosis. Primary cancers were mostly breast cancer, lung cancer, or hematologic malignancies. The mean Karnofsky performance score (KPS) was 65. Frequent clinical symptoms were visual complaints, headache, cranial neuropathy, focal weakness, and decreased awareness. Diagnosis was made based on clinical symptoms, cytological CSF analysis results, and/or magnetic resonance imaging findings. The median overall survival (OS) was 4 months (95% CI 2.48-5.52). Prognostic variables associated with a better OS were hematopoietic malignancies, KPS ≥ 70, absence of meningeal signs, receiving any form of treatment, normal CSF glucose levels, and normal CSF LDH levels. After bivariate analysis, high LDH in the CSF remained statistically significant as a poor prognostic indicator. The LDH level is a useful parameter to assess the prognosis of patients with NM. Other factors associated with the prognosis of these patients were tumor type, CSF glucose levels, performance status, and receiving any form of treatment.

[Presentation of a clinical case of systemic juvenile rheumatoid arthritis]. / Artritis reumatoide juvenil sistémica. Caso clínico.

A case of a 6-year-old male child was studied. Initially, he presented large-joint arthritis of the right knee and heel, with clinical data of systemic inflammation, such as fever, increase in sedimentation rate and leucocytosis, during more than six weeks of evolution. A wrong initial diagnosis of septic arthritis was made, but the lack of response to antibiotics and surgical drainage of the knee led to a trial with prednisone, which induced clinical remission. The patient remained hospitalized for 24 days and underwent surgical drainage, knee arthroscopy, two bone gammagrams, nuclear magnetic resonance, and antibiotics, as well as considerable stress and uncertainty for him and his family. Thus, it is very important to make an early diagnosis of juvenile rheumatoid arthritis and avoid complications. Recent literature was examined with special emphasis on opportune clinical diagnosis, as well as on therapeutic innovations, which have been able to modify the course of the disease and improve the quality of life of these patients. Pediatricians and general practitioners should take into account this diagnosis when seeing a patient with arthritis, especially when the signs point towards a systemic disease affecting two or more joints.