My patient with peripheral neuropathy was just diagnosed with monoclonal gammopathy of unclear significance (MGUS). Can these two conditions be related?

The presence of MGUS in patients with peripheral neuropathy (PN) may be either coincidental or causal. Younger age group (<50 y) and the presence of IgM MGUS increase the likelihood of a causal relationship between MGUS and peripheral neuropathy. 1

The likelihood of a causal relationship is higher in the younger age group because of the very low prevalence of M proteins (less than 1.5%) in this population making coincidental presence of MGUS and PN much less likely. In contrast, this relationship may just be coincidental in older patients because of higher baseline prevalence of MGUS (7% in those over 70 y old). 1  

Similarly, a causal relationship between MGUS and PN may be more likely when the M protein is IgM (vs IgG or IgA). In a study of patients with MGUS and peripheral neuropathy,  31% of patients with IgM MGUS had neuropathy vs 14% for IgA and 6% for IgG MGUS. In fact, among patients with PN without an obvious cause, the prevalence of an M protein may be as high as 10%.2  Whether the relationship between non-IgM MGUS and PN is causal remains unclear.3

Although the exact mechanism of MGUS-related PN is not known, pathologic studies in Waldenstrom macroglobulinemia and multiple myeloma have demonstrated demyelination and widened myelin lamellae associated with monoclonal IgM deposits.1

But before you implicate MGUS as the cause of PN, make sure to exclude common causes of PN, such as diabetes mellitus, alcoholism and potential drugs.

 

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References

  1. Chaudhry HM, Mauermann ML, Rajkumar SV. Monoclonal gammopathy—associated peripheral neuropathy: diagnosis and management. Mayo Clin Proc 2017; 92:838-50. https://www.mayoclinicproceedings.org/article/S0025-6196(17)30118-0/pdf
  2. Kelly JJ Jr, Kyle RA, O’Brien PC, et al. Prevalence of monoclonal protein in peripheral neuropathy. Neurology 1981;31:1480-83. https://www.ncbi.nlm.nih.gov/pubmed/6273767
  3. Nobile-Orazio E, Barbien L, Baldini L, et al. Peripheral neuropathy in monoclonal gammopathy of undetermined significance: prevalence and immunopathogenetic studies. Acta neurol Scand 1992;85:383-90. https://onlinelibrary.wiley.com/doi/10.1111/j.1600-0404.1992.tb06033.x
My patient with peripheral neuropathy was just diagnosed with monoclonal gammopathy of unclear significance (MGUS). Can these two conditions be related?

Should I routinely select antibiotics with activity against anaerobes in my patients with presumed aspiration pneumonia?

Anaerobes have been considered a major cause of aspiration pneumonia (AP) based on studies published in 1970’s (1-3). More recent data, however, suggest that anaerobes no longer play an important role in most cases of AP (4-7) and routine inclusion of specific anti-anaerobic drugs in their treatment is no longer necessary.

 
An important reason for anaerobes not playing an important role in AP in the current era is the change in the demographics of patients who may be affected. Patients reported in older studies often suffered from alcohol use disorder, drug ingestion, seizure disorders and acute cerebrovascular accident. In contrast, more recent data show that AP often occurs in nursing home residents, the elderly with cognitive impairment, and those with dysphagia, gastrointestinal dysmotility or tube feeding (8,9).

 
In addition, many cases of AP reported in older studies involved delay of 4 or more days before seeking medical attention and, not surprisingly, often presented with lung abscess, necrotizing pneumonia, empyema, or putrid sputum, features that are relatively rare in the current era.

 
Further supporting the diminishing role of anaerobes in AP, are recent microbiological studies of the respiratory tract in AP revealing the infrequent isolation of anaerobes and, even when isolated, often coexisting with aerobic bacteria. The latter observation is important because, due to the alteration in the redox potential (9,10), treatment of aerobic bacteria alone may lead to less oxygenation consumption and less favorable environment for survival of anaerobes in the respiratory tract.

 
We should also always consider the potential adverse effects of unnecessary antibiotics with anaerobic activity in our frequently debilitated patients, including gastrointestinal dysbiosis (associated with Clostridiodes difficile infections and overgrowth of antibiotic-resistant pathogens such as vancomycin-resistant enterococci (VRE), hypersensitivity reactions, drug interactions, and central nervous system toxicity (11,12).

 
Thus, the weight of the evidence does not justify routine anaerobic coverage of AP in today’s patients.

 

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References
1. Bartlett JG, Gorbach SL, Finegold SM. The bacteriology of aspiration pneumonia. Am J Med. 1974;56(2):202-7. https://www.ncbi.nlm.nih.gov/pubmed/4812076
2. Bartlett JG, Finegold SM. Anaerobic pleuropulmonary infections. Medicine (Baltimore). 1972;51(6):413-50. https://www.ncbi.nlm.nih.gov/pubmed/4564416
3. Bartlett JG, Gorbach SL. The triple threat of aspiration pneumonia. Chest. 1975;68(4):560-6. https://www.ncbi.nlm.nih.gov/pubmed/1175415
4. Finegold SM. Aspiration pneumonia. Rev Infect Dis. 1991;13 Suppl 9:S737-42. https://www.ncbi.nlm.nih.gov/pubmed/1925318
5. Bartlett JG. How important are anaerobic bacteria in aspiration pneumonia: when should they be treated and what is optimal therapy. Infect Dis Clin North Am. 2013;27(1):149-55. https://www.ncbi.nlm.nih.gov/pubmed/23398871
6. El-Solh AA, Pietrantoni C, Bhat A, Aquilina AT, Okada M, Grover V, et al. Microbiology of severe aspiration pneumonia in institutionalized elderly. Am J Respir Crit Care Med. 2003;167(12):1650-4. https://www.ncbi.nlm.nih.gov/pubmed/12689848
7. Marik PE, Careau P. The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: a prospective study. Chest. 1999;115(1):178-83. https://www.ncbi.nlm.nih.gov/pubmed/9925081
8. Bowerman TJ, Zhang J, Waite LM. Antibacterial treatment of aspiration pneumonia in older people: a systematic review. Clin Interv Aging. 2018;13:2201-13. https://www.ncbi.nlm.nih.gov/pubmed/30464429
9. Mandell LA, Niederman MS. Aspiration Pneumonia. N Engl J Med. 2019 Feb 14;380(7):651-663. doi: 10.1056/NEJMra1714562. https://www.ncbi.nlm.nih.gov/pubmed/30763196
10. Walden, W. C., & Hentges, D. J. (1975). Differential effects of oxygen and oxidation-reduction potential on the multiplication of three species of anaerobic intestinal bacteria. Applied microbiology, 30(5), 781–785. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC187272/
11. Sullivan A, Edlund C, Nord CE. Effect of antimicrobial agents on the ecological balance of human microflora. Lancet Infect Dis. 2001;1(2):101-14. https://www.ncbi.nlm.nih.gov/pubmed/11871461
12. Bhalla A, Pultz NJ, Ray AJ, Hoyen CK, Eckstein EC, Donskey CJ. Antianaerobic antibiotic therapy promotes overgrowth of antibiotic-resistant, gram-negative bacilli and vancomycin-resistant enterococci in the stool of colonized patients. Infect Control Hosp Epidemiol. 2003;24(9):644-9. https://www.ncbi.nlm.nih.gov/pubmed/14510245

 

Contributed by Amar Vedamurthy, MD, MPH, Mass General Hospital, Boston, MA

Should I routinely select antibiotics with activity against anaerobes in my patients with presumed aspiration pneumonia?

My hospitalized patient with sepsis has persistently elevated lactic acid despite volume resuscitation, source control, and adequate oxygenation. What could I be missing?

Although the causes of lactic acidosis are legion (eg, sepsis, tissue hypoperfusion, ischemic bowel, malignancy, medications, liver dysfunction), thiamine deficiency (TD) is an often-overlooked cause of persistently elevated serum lactic acid (LA) in critically ill hospitalized patients,1 reported in 20-70% of septic patients.2  Septic shock patients may be particularly at risk of TD because of increased mitochondrial oxidative stress, decreased nutritional intake and presence of comorbid conditions (eg,  alcoholism, persistent vomiting).3

Early recognition of TD in hospitalized patients may be particularly difficult because of the frequent absence of the “classic” signs and symptoms of Wernicke’s encephalopathy (eg, ataxia, cranial nerve palsies and confusion) and lack of readily available confirmatory laboratory tests.4

TD-related lactic acidosis should be suspected when an elevated LA persists despite adequate treatment of its putative cause(s) (4,5). Administration of IV thiamine in this setting may result in rapid clearance of LA.3-5

TD causes lactic acidosis type B which is due to the generation of excess LA, not impairment in tissue oxygenation, as is the case for lactic acidosis type A. Thiamine is an essential co-factor in aerobic metabolism, facilitating the conversion of pyruvate to acetyl-CoA which enters the citric acid (Krebs) cycle within the mitochondria. In TD, pyruvate does not undergo aerobic metabolism and is converted to LA instead, leading to lactic acidosis.

Bonus pearl: Did you know that because of its limited tissue storage, thiamine stores may be depleted within only 3 weeks of reduced oral intake!

References

  1. O’Donnell K. Lactic acidosis: a lesser known side effect of thiamine deficiency. Practical Gastroenterol March 2017:24.   https://www.practicalgastro.com/article/176921/Lactic-Acidosis-Lesser-Known-Side-Effect-of-Thiamine-Deficiency
  2. Marik PE. Thiamine: an essential component of the metabolic resuscitation protocol. Crit Care Med 2018;46:1869-70. https://journals.lww.com/ccmjournal/Fulltext/2018/11000/Thiamine___An_Essential_Component_of_the_Metabolic.23.aspx
  3. Woolum JA, Abner EL, Kelly A, et al. Effect of thiamine administration on lactate clearance and mortality in patients with septic shock. Crit Care Med 2018;46:1747-52. https://journals.lww.com/ccmjournal/Fulltext/2018/11000/Effect_of_Thiamine_Administration_on_Lactate.5.aspx
  4. Kourouni I, Pirrotta S, Mathew J, et al. Thiamine: an underutilized agent in refractory lactic acidosis. Chest 2016; 150:247A. https://journal.chestnet.org/article/S0012-3692(16)56459-9/pdf
  5. Shah S, Wald E. Type B lactic acidosis secondary to thiamine deficiency in a child with malignancy. Pediatrics 2015; 135:e221-e224. http://pediatrics.aappublications.org/content/135/1/e221

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My hospitalized patient with sepsis has persistently elevated lactic acid despite volume resuscitation, source control, and adequate oxygenation. What could I be missing?