RU2800847C1 - Method of the treatment of polyneuropathy associated with gluten-sensitive celiac disease - Google Patents

Abstract

FIELD: medicine, therapy.

SUBSTANCE: invention can be used to treat polyneuropathy associated with gluten-sensitive celiac disease. The patient follows a gluten-free diet, takes vitamin and mineral complexes. Additionally, cascade plasma filtration is carried out with filters with a pore size of 10–12 nm when using 4–5 procedures in 1–2 days with a repetition of the course of treatment every 3–4 months for 2–3 years.

EFFECT: invention provides increased efficiency in the treatment of polyneuropathy associated with gluten-sensitive celiac disease by reducing the manifestations of sensory polyneuropathy in the form of restoration of pain sensitivity, reducing the severity of dysesthesia manifestations, reducing the severity of limb-trunk ataxia, and increasing the rate of propagation of excitation along sensory fibers according to stimulation electroneuromyography.

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Description

The invention relates to medicine and can be used in the treatment of polyneuropathy associated with gluten-sensitive celiac disease.

A known method of treating polyneuropathy by maintaining the vital functions of the body, primarily respiration and circulation [1 - Balabolkin M.I., Kreminskaya V.M. Diabetic polyneuropathy. Journal of Neurology and Psychiatry. Korsakov. - 2000. - No. 10. - With. 67-74]. This method is accepted as analog.

A known method for the treatment of polyneuropathy, including gluten-free diet, replenishment of deficiency of vitamins and minerals, control of pain [2 - Strokov I.A., Barinov A.N. Clinic, pathogenesis and treatment of pain in diabetic polyneuropathy. Neurological journal. - 2001, No. 6, p. 47-54]. This method is taken as a prototype. However, this method does not cover the treatment of sensory disorders in polyneuropathies associated with gluten-sensitive celiac disease.

The goal is to increase the effectiveness of the treatment of polyneuropathies associated with gluten-sensitive celiac disease.

The technical result consists in the fact that in a method for the treatment of polyneuropathy associated with gluten-sensitive celiac disease, including a gluten-free diet, intake of vitamin-mineral complexes, cascade plasma filtration is additionally performed with filters with a pore size of 10-12 nm using 4-5 procedures every 1-2 days with a repetition of the course of treatment every 3-4 months for 2-3 years.

The method is implemented as follows.

Gluten-sensitive celiac disease is manifested by the development of a syndrome of impaired absorption with impaired vitamin and mineral metabolism, protein-energy deficiency with the development of iron deficiency anemia, osteopenia, and edema. Damage to enterocytes is accompanied by the development of crypt hypertrophy, an increase in myoepithelial lymphocytes, and autoimmune lesions of various organs.

Polyneuropathies associated with gluten-sensitive celiac disease are predominantly sensory in nature and are manifested by a burning sensation, tingling, numbness in the feet and hands, a decrease in pain, vibration and temperature sensitivity in the distal legs. Patients have diffuse paresthesias that are noted on the face, trunk, thighs, buttocks. Signs of sensitive ataxia are revealed in the form of instability in the Romberg position or impaired tandem walking, restless legs syndrome. Involvement of thin nerve conductors leads to the development of mild weakness of the muscles of the distal legs.

Electroneuromyography reveals signs of axonopathy involving sensory and sensorimotor fibers. However, in a standard study, when fine fibers are affected, mosaic lesions are observed.

Clinically, patients report abdominal pain, bloating, occasional diarrhea, and fatigue. In serological diagnosis of gluten-sensitive celiac disease, anti-gliadin antibodies, antibodies to endomysium, and antibodies to tissue transglutaminase are detected.

Radiologically, lesions of the upper upper sections of the small intestine are observed - from the bulbous section of the duodenum to the proximal section of the jejunum, the contours of the intestine are straightened, become smooth, the mucosal folds are rare. The distance between them increases, they are shortened and compacted. A picture of hypotonic, tightly filled with a contrast suspension and with straightened contours of the loops of the small intestine is revealed.

The patients were on a gluten-free diet, took vitamin and mineral complexes, and underwent cascade plasma filtration procedures.

Patients undergo 4-5 cascade plasma filtration procedures. During each cascade plasma filtration procedure, 1210 ml (80% VCP) of plasma is treated using an Evaflux 2A20 plasma filter. Compensation is carried out with 500 ml of saline and 200 ml of 20% albumin solution.

Cascade (double) plasma filtration is an extracorporeal method for purifying human blood plasma, in which pathogenic molecules are removed from the plasma flow as part of high-molecular plasma components.

The Fvaflux™ Plasma Fractionator has a cylindrical plastic body with porous capillary membranes inside. The membrane material is a polymer of ethylene and vinyl alcohol. The total surface area of the membranes is 2 square meters. m. Filling volume of the filter (free volume) - 140 ml, the filter is filled with sterile pyrogen-free water.

The Evaflux 2A20 filter has a pore size of 10-12 nm, which is recommended by the manufacturer for autoimmune diseases.

Patients tolerate the plasma filtration procedure satisfactorily, no pathological reactions were recorded. Apply 4-5 procedures in 1-2 days with a repetition of the course of treatment every 3-4 months for 2-3 years. As a result of the treatment, the signs of diffuse paresthesia and partial restoration of pain and vestibular sensitivity are reduced.

Electroneuromyography of the median nerves was performed: the left - the speed of excitation before plasma filtration was 39 m/s, after - 43 m/s \ norm - 50 m/s, the right - the speed of excitation was before plasma filtration was 37 m/s, after - 46 m \s (norm 50 m\s). Elektroneuromyography of the ulnar nerves was performed: the left - the speed of excitation before plasma filtration was 34 m/s, after - 39 m/s (normal - 50 m/s), the right - the speed of excitation was before flame filtration was 37 m/s, after - 39 m/s (norm 50 m/s). The results indicate a gradual recovery of the rate of conduction of excitation along the nerve fibers, which indicates the effectiveness of the treatment according to the proposed method.

The method is confirmed by the following examples.

Example 1

Patient A., 46 years old, was admitted with complaints of torso ataxia when walking and in a sitting position (in the form of pushes of the torso back); general weakness, non-systemic dizziness and constant tinnitus and a feeling of "rustling"; daily pressing headache in the temporo-parietal region, often with an accent on the left, sometimes accompanied by a feeling of nausea, VAS intensity up to 8 points; a feeling of numbness in the feet and legs up to the level of the knees; for bloating and rumbling in the abdomen, discomfort behind the sternum when swallowing dry and solid food, for frequent belching (every 5 minutes), weight loss by 12 kg in 2 years.

HISTORY OF DISEASE: He considers himself ill since 2015, when diarrhea, rumbling and bloating appeared, for which he was repeatedly treated in the therapeutic department of Zvenigorod, blood tests revealed a decrease in hemoglobin to 34 g / l, took courses of iron preparations with unstable effect.

She was examined on an outpatient basis in December 2017: fecal analysis for shigellosis, salmonellosis, yersiniosis was negative, M - gradient was not detected.

In January 2018, inpatient treatment was carried out at the Zvenigorod Central City Hospital: ultrasound of the OBP diffuse changes in the liver and pancreas, gallstone disease, chronic calculous cholecystitis, ultrasound of the thyroid gland and regional lymph nodes no pathology, colonoscopy was performed up to the transverse section of the colon, colon polyps, adhesive process in abdominal cavity.

On February 20, 2018, she was examined and treated in the Department of Inflammatory Bowel Diseases. Enterography: X-ray signs of pathology, including Crohn's disease, from the side of the small intestine are not determined. Gastroptosis 3 tbsp. Enteroptosis. Pelvic position of the caecum.

Colonoscopy: the endoscope was passed to the splenic flexure: no organic pathology was detected

EGDS: chronic gastritis with mucosal atrophy, endoscopic picture 12 p.k. characteristic of celiac disease.

Post-bulb duodenal biopsy: Biopsy from the post-bulb duodenum shows the morphology of chronic atrophic duodenitis may be consistent with celiac disease (Marsh stage 3C). The patient began to adhere to a gluten-free diet.

In 2019, hospitalization in the NPK department for therapy correction. The treatment was carried out in/in the treatment with prednisolone, calcium, potassium, vitamins C and group B, glucose with improvement in the form of weight gain by 3 kg, improvement in general well-being, at discharge the stool was semi-formed up to 2 times a day. According to the patient, she occasionally violated the gluten-free diet.

With endoscopy, endoscopic signs of superficial gastritis are determined. Duodenitis with signs of mucosal atrophy, biopsy: the morphological picture corresponds to celiac disease during treatment with a gluten-free diet. Compared with biopsy (morphological conclusion), there is a pronounced positive trend in the form of a significant decrease in the number of MELs, an increase in the height of the villi and the depth of the crypts.

Since 2015, she has been experiencing breathing difficulties in the form of the inability to take a deep breath, frequent yawning. Anxiety has risen. Since that time, he has noted the appearance of coordinating disorders in the form of staggering when walking, fear of falling from dizziness. Trembling in the limbs was not noted. There were alternating sensations of "freezing" and "burning" of the head in the temporo-parietal region on both sides. Violation of night sleep in the form of difficulty falling asleep after a long walk during the day. Convulsive contractions of the muscles of the lower extremities bothered from 2015 to 2017 before the diagnosis was established and the treatment was corrected. There are signs of diffuse sensorimotor paresthesia and a decrease in pain sensitivity according to the polyneuritic type.

According to the survey:

EEG: Minor changes in the bioelectrical activity of the brain of a regulatory nature. No typical forms of epi-activity have been identified.

Spirometry: Normal spirogram. VC 3.31 L, 133%, FVC 3.47 L, 137%, FEV1 2.71 L, 125%, FEV1/VC 81.9%.

ENMG: ENMG signs of sensory polyneuropathy (with a primary lesion of both superficial peroneal nerves).

ECHO-KG: Aorta of medium echogenicity, not dilated. The leaflets of the aortic valve are sealed, the amplitude of disclosure is sufficient. The leaflets of the mitral valve are sealed, the movement is in antiphase. The chambers of the heart are not dilated. Global LV systolic function is not reduced (Simpson EF 58%). Violations of local contractility of the LV myocardium were not detected. Violation of the diastolic function of the left ventricle of the 1st type. There were no signs of pulmonary hypertension. There is no fluid in the pericardial cavity. Aortic regurgitation 0 st. Mitral regurgitation 0 1 st. Tricuspid regurgitation 1

X-ray of the chest organs in 2019 did not reveal fresh and infiltrative changes.

MSCT from 2020 CT showed no signs of "fresh" focal and infiltrative changes in neoplasms in the lungs. At the time of the CT scan, there were no signs of viral pneumonia.

PCR 2020 SARS Coronavirus RNA Not detected.

IMG AT IgM to Coronavirus (SARS CoV 2) 0.42, AT IgG to Coronavirus (SARS CoV 2) 62.00 Past diseases: Celiac disease, latent form, first detected. Malabsorption syndrome grade 2 with electrolyte disturbances. Protein energy deficiency of the 3rd degree. Circulating protein deficiency grade 2. Deficiency in body weight. Chronic gastroduodenitis, not associated with Hp. Chronic cholecystitis, cholecystolithiasis.

PHYSICAL EXAMINATION: General condition: Moderate. General examination: Active position. Power is reduced. Skin of normal color. Turgor is reduced. Lymph nodes are not palpable. There are no peripheral edema. Self-service is preserved in full. Respiratory organs: Breathing through the nose is free. The number of breaths is 16 per minute. Percussion sound pulmonary. Respiration vesicular weakened. Wheezes are not heard. Circulatory organs: the boundaries of the heart are not expanded, no murmurs are heard, heart sounds are muffled, the rhythm is correct, the pulse is 70 per minute. BP 90/60 mmHg Digestive organs: tongue moist. The abdomen is soft, painless, of the usual form. The liver is not palpable, the spleen is not palpable. The chair is not changed. Urinary system: Urination is not quickened, Pasternatsky's symptom is negative on both sides. Height 149 cm, Weight 33.5 kg.

NEUROLOGICAL STATUS: Consciousness is clear. There are no meningeal symptoms. Memory, thinking, speech and perception are not impaired. Oriented in place, time and self correctly. Brief mental status assessment scale 28 points. The mood is calm. Psychotic and delusional symptoms are absent. Hospital Anxiety and Depression Scale 18/14. SOMS 2 27 points. Cranial nerves: Sense of smell is not changed. Fields of view are not limited. Full eyeball movement. Pupils of medium size, S=D. The palpebral fissures are not changed, S=D. Direct and cross photoreactions of the pupils are saved. Convergence is satisfactory. Nystagmus is absent. Sensitivity on the face is not changed. Strength in chewing muscles 5/5 points according to MRC on both sides. The face is symmetrical, mobile. Hearing is not reduced. Swallowing is not disturbed. Phonation saved. Speech is clear and understandable. Strength in the sternocleidomastoid and trapezius muscles 5/5 points according to MRC on both sides. Tongue in the midline. Muscle tone is not changed, D=S. Muscle strength in the upper and lower limbs 5/5 points according to MRC on both sides. Tendon reflexes of medium liveliness, S=D on the arms; knee and Achilles are slightly reduced. There are no pathological symptoms. Performs coordinating tests (nose finger, heel-knee) with slight intentional trembling. In the Romberg position, significant instability with a tendency to fall. Painful hypoesthesia of the polyneuritic type in the legs to the level of the knees and in the hands in the hands and forearms. Vibration and deep sensitivity are not changed. Pelvic functions are controlled. Walking with elements of "braid weaving". Trunk ataxia.

LABORATORY AND INSTRUMENTAL INDICATORS:

CBC: Hemoglobin 11.6 (12.0-14.0) g/dl; Erythrocytes 3.45 (3.90-4.70) 10 ^∧ 6/µl; Wed hemoglobin content in erythrocytes 26.3 (27.0-31.0) pg; Average erythrocyte volume 86.2 (80.0-100.0) fl; Wed erythrocyte hemoglobin concentration 32.9 (30.0-38.0) g/dl; Hematocrit 38.4 (36.0-42.0)%; Platelets 204 (180-320) 10 ^∧ 3/µl; Average platelet volume 8.80 (7.40-12.00) fl; Leukocytes 7.52 (4.00-9.00) 10 ^∧ 9/l; Neutrophils 67.00 (48.00-78.00)%; Eosinophils 2.0 (0.5-5.0)%; Monocytes 5.3 (3.0-11.0)%; Lymphocytes 23.30 (19.00-37.00)%; Basophils 0.5 (0.0-1.0)%; Neutrophils abs. 5.04 (2.00-7.50) 10 ^∧ 9/L; Eosinophils abs. 0.15 (0.02-0.30) 10 ^∧ 9/l; Monocytes abs. 0.40 (0.09-0.60) 10 ^∧ 9/l; Abs. lymphocytes 1.75 (1.20-3.00) 10 ^∧ 9/l; Basophils abs. 0.04 (0.00-0.07) 10 ^∧ 9/l.

Biochemical research:

Total protein 51.0 (64.0-83.0) g/l; Albumin 31.9 (34.0-48.0) g/l; ALT 18.9 (0.01-35.0) U/l; ACT 22.7 (0.01-35.0) U/L; Bilirubin total 7.0 (5.0-21.0) µmol/l; Direct bilirubin 1.4 (0.01-5.0) µmol/l; Bilirubin indirect 5.6 (0.01-16.0) µmol/l; Glucose 4.48 (4.10-5.90) mmol/l; Creatinine 72 (53-97) µmol/l; Urea 4.06 (2.10-7.20) mmol/l; Potassium 4.09 (3.50-5.10) mmol/l; Sodium 142.7 (136.0-145.0) mmol/l; Triglycerides 1.17 (0.00-1.70) mmol/l; Total cholesterol 4.66 (3.10-5.20) mmol/l; Gamma Glutamyltransferase 17.6 (0.01-38.0) U/l; Alkaline phosphatase 64.2 (30.0-120.0) U/l; Uric acid 241.0 (155.0-357.0) µmol/l.

Coagulogram:

APTT 28.1 (25.4-36.9) sec; MHO 1.18 (0.90-1.20); Prothrombin according to Quick 82.0 (70.0-130.0)%; Prothrombin time 13.4 (9.4-12.5) sec; Fibrinogen calculated 3.25 (2.00-4.00) g/l.

ENMG: Signs of sensory polyneuropathy (with a primary lesion of both superficial peroneal nerves).

NEUROLOGIST'S CONSULTATION

Main diagnosis: Chronic sensorimotor polyneuropathy associated with celiac disease. Gluten ataxia, MR-spectroscopically negative. Functional neurological disorders. Panic attacks. Celiac disease, latent form. Cachexia (BMI 15.2).

Concomitant disease: Celiac disease, latent form. Malabsorption syndrome grade 2 with electrolyte disturbances. Cachexia (BMI 13.96 kg/m2). Gastroptosis 3 degrees. Enteroptosis. Chronic gastroduodenitis, not associated with H. pylori, in the stage of subsiding exacerbation. Gallstone disease: cholecystolithiasis.

The patient was on a gluten-free diet and took vitamin-mineral complexes.

The patient underwent 4 sessions of cascade plasma filtration. During each cascade plasma filtration procedure, 1210 ml (80% VCP) of plasma was processed using the Evaflux 2A20 plasma filter. Replacement: 500 ml saline, 200 ml 20% albumin solution. The patient tolerated all procedures satisfactorily. It is recommended to repeat the course of treatment every 3 months for 2 years.

After the treatment in the neurological status, positive dynamics is clinically noted in the form of improved sensitivity in the distal lower extremities, a decrease in the severity of ataxia when walking.

According to the stimulation electroneuromyography of the sensory fibers of the distal nerves of the upper extremities, the dynamics of recovery of the excitation propagation velocity (ESV) is noted: in the median nerve on the left, the SVV before plasma filtration was 39 m/s, after - 45 m/s (normal ≥50 m/s), on the right SV before plasma filtration was 37 m/s, after - 47 m/s (normal ≥50 m/s), in the ulnar nerve on the left NRV before plasma filtration was 34 m/s, after - 41 m/s (normal ≥50 m/s) , on the right, the SRV before plasma filtration was 37 m/s, after - 42 m/s (normal ≥50 m/s).

Example 2

Patient L., aged 53, was admitted with complaints of decreased sensation in the feet; on sensations of "burning", "twisting" in the area of the legs, which occurs during sleep at night, awakening the patient, decreasing when moving the legs and rubbing the muscles of the legs; on instability when walking; to the noise in the head; for pain in the epigastrium, nausea and vomiting in violation of the diet - the use of dried meat, fatty foods, periodically itching of the skin, stools 1-2 times a day, semi-formed or formed without pathological impurities, the temperature is normal.

HISTORY OF DISEASE: He considers himself ill since January 2016, when his appetite began to decrease (he lost 20 kg), loose stools. He was examined and treated at the place of residence, received conservative treatment with enzymatic preparations without positive dynamics. On an outpatient basis in December 2016, he was examined for tuberculosis and celiac disease, the results are negative. In December 2016, he was again hospitalized in the hospital. Conducted conservative therapy: pancreatin, omeprazole, but shpa, Vit B 12, actovegin, Linex, albumin. Discharged with minor improvement. Recommended intake of enzymes and probiotics. Followed the recommendations.

At the end of January 2017, he was hospitalized in the therapeutic department of Astrakhan. Conducted a survey in b / chemical analysis of blood noted cytolytic syndrome ACT 128; ALT: 68 Bilirubin 32; Total protein 43.3 g/l; albumin 21.6 g/l In the clinical analysis of blood: the results are within the normal range. According to CT of the chest cavity Pneumofibrotic changes with numerous bronchiectasis, arcade pulmonary consolidation in/lobe of the right lung. Abdominal CT scan Ascites. Diffuse changes in the hepatic parenchyma of the liver. cholelithiasis, gallbladder calculus. Chr. pancreatitis. According to the ECG dated February 1, 2017. Arrhythmia. Ultrasound of the thyroid gland, the thyroid gland is not enlarged, with a smooth contour, normal echogenicity, homogeneous, on the left isoechogenic homogeneous node 9 mm. AFP from 1.02.2017 - 5 IU/ml (0-14) According to endoscopy, insufficiency of the cardia and pylorus. Chronic superficial gastritis. In visible areas without signs of acute inflammation. The tone of the intestine is increased.

The examination revealed celiac disease based on a morphological study of the mucous membrane of the small intestine and an increase in antibodies to gliadin and tissue transglutaminase.

Blood test: AT to gliadin (IgA) 100.0 U/ml, AT to gliadin (IgG) 93.0 U/ml, AT to tissue transglutaminase (IgA) 200.0 U/ml, AT to tissue transglutaminase (IgG) 22.1 U/ml, AT to deamidated gliadin peptides (IgA) 100.0 U/ml, AT to deamidated gliadin peptides (IgG) 100.0 U/ml.

He was transferred to the NPK department, where therapy was carried out. Has been examined.

Ultrasound of the OBP: echo signs of enlargement (due to the left lobe) and pronounced diffuse changes in the liver, cholecystitis, edema of the gallbladder walls. Cholecystolithiasis. Diffuse changes in the pancreas. A small amount of free fluid in the abdominal cavity. Severe flatulence

EGDS: Superficial gastritis. Biopsy. The histological picture of atrophic jejunitis is characteristic of celiac disease at the March 3 stage.

CT scan of the chest: CT signs of right-sided thromboembolism of segmental branches C9 C10 of the pulmonary artery. There were no signs of pneumonia.

There were no destructive and traumatic changes in the skull.

X-ray examination of the chest: Rg does not determine signs of pathology from the chest organs. Post-inflammatory changes in the right lung.

CT OB: MSCT picture of diverticulosis of the jejunum. Pneumatosis and moderate dilatation of the loops of the small intestine. Compaction of fatty tissue of the abdominal cavity and retroperitoneal space. Free fluid in the pelvic cavity. Data for the presence of volumetric formations of the intestine is not received. Chronic calculous cholecystitis. fatty hepatosis.

Was discharged for outpatient treatment, for 3 months. after hospitalization, he gained weight by 20 kg, up to 69 kg, after which the weight stabilized. He took enzymes, pradaxa for 1 month. Follows the diet. A real aggravation of the last 2 weeks, when the above complaints intensified. Hospitalized for examination and treatment. Physical examination data:

PHYSICAL EXAMINATION: General condition: moderate severity, malnutrition, asthenic constitution. Height 170 cm, weight 69 kg. BMI 23.8. The skin is pink. Lymphatic system: on examination, the peripheral lymph nodes are not palpable. Muscular system: the general development of the muscular system is not disturbed

Respiratory organs: no complaints. Respiratory rate 16 per minute at rest. Percussion of the lungs: a comparative sound is clear pulmonary, dullness of percussion sound is not noted. Auscultation of the lungs: vesicular breathing is determined by auscultation over the lungs. Cardiovascular system: no complaints. When examining the vessels of the neck, a pulsation of the carotid arteries is noted. The apex beat is not visible, palpable in the fifth intercostal space 1 cm outward from the midclavicular line. Border of relative dullness of the heart: Right 1 cm outward from the right edge of the sternum. Left along the left midclavicular line. Upper at the level of 3 ribs. Heart sounds are rhythmic. Heart rate 72 per minute. Blood pressure 120/70 mm Hg.

Digestive organs: complaints, see above. The tongue is coated with a whitish coating. Abdomen: not tense, sensitive on palpation in the right hypochondrium. The liver is not enlarged, does not protrude from under the edge of the costal arch. The spleen is not palpable. There are no symptoms of peritoneal irritation. Stool regular 1 2 times a day without impurities, normal color.

Organs of urination: no complaints. The area of the kidneys is not changed, the kidneys are not palpable. The symptom of tapping is negative on both sides. Urination is not disturbed.

NEUROLOGICAL STATUS: consciousness is clear, contact, oriented correctly in place, time and self. There are no meningeal symptoms. Brief mental status assessment scale - 30 points. Hospital anxiety and depression scale - 14/12 points. The mood background is reduced. Astenized. Signs of motor and sensory aphasia are not determined. Cranial nerves: The sense of smell is not changed. Fields of view are not limited. Full eyeball movement. Pupils of medium size, S=D; palpebral fissures are not changed, S=D; direct and cross photoreactions are preserved, convergence is weakened, nystagmus. The face is symmetrical. Swallowing is not disturbed. Phonation saved. Tongue in the midline. Muscle tone is not changed, D=S. Muscle strength in the upper and lower limbs 5/5 points. Tendon reflexes are reduced, S=D. There are no pathological symptoms. Performs coordination tests (finger-nose, heel-knee) with action tremor without passing by. Dysadiadochokinesis is absent. There is no dysmetria. Staggering in the Romberg position. Decreased pain sensitivity of the "sock" type. When checking the two-dimensional-spatial sensitivity, single errors. Tactile sensitivity is not changed. Pelvic functions are controlled. Walks on his own. Tension symptoms are negative.

LABORATORY AND INSTRUMENTAL INDICATORS:

CBC: Hemoglobin 12.8 (13.0-16.0) g/dl; Erythrocytes 3.08 (4.00-5.00) 10 ^∧ 6/µl; Wed hemoglobin content in erythrocyte 23.0 (27.0-31.0) pg; The average volume of an erythrocyte is 80.4 (80.0-100.0) fl; Wed erythrocyte hemoglobin concentration 26.5 (30.0-38.0) g/dl; Hematocrit 35.9 (40.0-48.0) g/l; Platelets 305 (180-320) 10 ^∧ 3/µl; Average platelet volume 7.10 (7.40-12.00) fl; Leukocytes 2.92 (4.00-9.00) 10 ^∧ 9/l; Neutrophils 48.00 (48.00-78.00)%; Eosinophils 1.3 (0.5-5.0)%; Monocytes 8.2 (3.0-11.0)%; Lymphocytes 39.60 (19.00-37.00)%; Basophils 0.4 (0.0-1.0)%; Neutrophils abs. 1.40 (2.00-7.50) 10 ^∧ 9/l; Eosinophils abs. 0.04 (0.02-0.30) 10 ^∧ 9/l; Monocytes abs. 0.24 (0.09-0.60) 10 ^∧ 9/l; Abs. lymphocytes 1.16 (1.20-3.00) 10 ^∧ 9/l; Basophils abs. 0.01 (0.00-0.07) 10 ^∧ 9/l;

Biochemical blood test: Total protein 57.9 (64.0-83.0) g/l; Albumin 32.8 (34.0-48.0) g/l; ALT 18.3 (10.0-40.0) U/l; ACT 30.0 (15.0-40.0) U/L; Bilirubin total 23.9 (5.0-21.0) µmol/l; Direct bilirubin 6.4 (0.0-3.4) µmol/l; Bilirubin indirect 17.5 (0.0-15.9) µmol/l; Glucose 4.30 (4.10-5.90) mmol/l; Creatinine 87 (80-115) µmol/l; Urea 4.20 (2.10-7.10) mmol/l; Potassium 4.98 (3.50-5.10) mmol/l; Sodium 142.8 (136.0-145.0) mmol/l; Chlorine 104.1 (98.0-107.0) mmol/l; Calcium total 2.53 (2.15 2.50) µmol/l; Iron 30.0 (11.6 31.3) µmol/l; Total cholesterol 4.77 (0.00-5.18) mmol/l; Alpha amylase 78 (28-100) U/l; Gamma Glutamyltransferase 49 (0-55) U/l; Alkaline phosphatase 104.0 (30.0-120.0) U/l; C reactive protein 3.14 (0.001-5.00) mg/l.

Immunological studies: AT to gliadin (IgA) 100.0 (0.01-12.0) U / ml; AT to gliadin (IgG) 23.9(0.0-12.0) U/ml; AT to tissue transglutaminase (IgA)>200; AT to tissue transglutaminase (IgG) 8.1 (0.01-10.0) U/ml; AT to deamidated gliadin peptides (IgA) 100.0 (0.01-10.0) U/ml; AT to deamidated gliadin peptides (IgG) 100.0 (0.01-10.0) U/ml;

X-ray of the small intestine: The act of swallowing is not disturbed. 12 duodenum: it is not possible to assess the relief due to fluid in the intestinal lumen, which interferes with the adhesion of the colon and the formation of a secondary relief, the lumen is not narrowed, the transit is accelerated. In the ascending section, there are two diverticula of a rounded shape, with even clear contours, 21 and 11 mm in size, the width of the lumen of the orifice is 4 and 3 mm, respectively. After a portion oral intake of 200 ml of barium suspension, the filling of the loops of the small intestine is slow, uneven. There is fluid in the lumen of the small intestine, which interferes with the adhesion of the contrast agent and the formation of a secondary relief. Loops of the jejunum: the width of the lumen is normal, the relief of the mucosa is pinnate, represented by Kerckring folds, the tone is preserved, the peristalsis is symmetrical. In the jejunum, multiple diverticula are visualized, with even, clear contours, ranging in size from 5.8 to 45.5 mm, containing fluid and mucus, the contours are even and clear.

After 4 hours from the start of the study and a stimulating breakfast, the colon does not fill (the gastroleal reflex is reduced). In the visible loops of the ileum, there were no areas of persistent narrowing, no rebuilt relief, peristalsis was weakened, and the tone was reduced.

After 6 hours, the right flank of the colon is not tightly filled. Terminal ileum: peristalsis is symmetrical, active, the relief is preserved, palpation is painless, the lumen is not narrowed.

Conclusion: Rg signs of duodenal diverticulosis 12 without signs of inflammation and penetration. Diverticulosis of the jejunum with symptoms of malabsorption, without signs of inflammation and penetration. Dyskinesia of the stomach with accelerated evacuation and delayed uneven filling of the loops of the small intestine.

Ultrasound of the abdominal organs. kidneys, adrenal glands and retroperitoneal space:

Liver - the contours are even, clear, not enlarged, the echogenicity of the parenchyma is average, the structure is homogeneous, the vascular pattern is not changed. Intrahepatic bile ducts are not dilated. Hepaticocholedochus 8 mm in diameter, poorly visible distally. Gallbladder - 10×4.5 cm, S-shaped inflection in the neck, wall 2.7 mm, homogeneous bile in the lumen. Pancreas - the head of the usual form is 21 mm, the body is 10 mm, the tail is not visible (the norm is up to 30 mm), the echogenicity of the parenchyma is diffusely heterogeneous, the GPP is 2 mm in diameter. Kidneys - not changed. Spleen - 12.2×4 cm, echo homogeneous.

Conclusion: Moderate expansion of hepaticocholedochus. Diffuse changes in the pancreas.

Esophagogastroduodenoscopy: The device Fujinon EG 590 WR was freely passed into the esophagus. The esophagus is not deformed, the walls are smooth, elastic, the mucosa is pink. The level of the esophageal-gastric junction is 40 cm from the incisors. Z line is clear, uneven. The cardia closes completely. The stomach is not deformed, it straightens well during insufflation. In the lumen of the stomach, a small amount of mucous contents mixed with bile. The folds of the mucosa are longitudinal, tortuous, and almost completely straighten out during insufflation. The gastric mucosa is pink with foci of hyperemia, the vascular pattern is not changed. Peristalsis can be traced in all departments. The gatekeeper is not deformed, closes, we pass freely. The bulb of the duodenum is medium in size, the mucosa is pink. The postbulbar parts of the duodenum are not deformed, the mucosa is pink, the folds are low and thin. In the lumen of the intestine bile. Urease test after 15 minutes is negative. Biopsy: 2fr for disaccharidase deficiency and 2fr for celiac disease. Conclusion: Chronic gastritis. Duodeno gastric reflux.

ENMG: Slow conduction along the sensory fibers of both ulnar and median nerves. No pathology was found in the motor fibers.

NEUROLOGIST'S CONSULTATION

Main diagnosis: Chronic sensorimotor polyneuropathy associated with celiac disease. Secondary Restless Leg Syndrome.

Concomitant disease: Celiac disease, latent form. Chronic gastroduodenitis, not associated with Hp, moderate exacerbation. Diverticular disease of the duodenum and jejunum. Chronic pancreatitis without exacerbation. Functional hyperbilirubinemia.

The patient was on a gluten-free diet and took vitamin-mineral complexes.

The patient underwent 5 procedures of cascade plasma filtration. All procedures were well tolerated by the patient. During each cascade plasma filtration procedure, 1210 ml (80% VCP) of plasma was processed using the Evaflux 2A20 plasma filter. Replacement: 500 ml saline, 200 ml 20% albumin solution. The Evaflux™ Plasma Fractionator has a cylindrical plastic body with porous capillary membranes inside. The membrane material is a polymer of ethylene and vinyl alcohol. The total surface area of the membranes is 2 square meters. m. Filling volume of the filter (free volume) - 140 ml, the filter is filled with sterile pyrogen-free water. The Evaflux 2A20 filter has a pore size of 12 nm, which is recommended by the manufacturer for autoimmune diseases. It is recommended to repeat the course of treatment every 3 months for 2 years.

After the treatment, the neurological status clinically showed positive dynamics in the form of an increase in pain sensitivity in the distal lower extremities, regression of the restless legs syndrome.

According to the stimulation electroneuromyography of the sensory fibers of the distal nerves of the upper extremities, the dynamics of recovery of the excitation propagation velocity (ESV) is noted: in the median nerve on the left, the SVV was 38 m/s before plasma filtration, after - 42 m/s (normal ≥50 m/s), on the right SV before plasma filtration was 46 m/s, after - 51 m/s (normal ≥50 m/s), in the ulnar nerve on the left NRV before plasma filtration was 40 m/s, after - 46 m/s (normal ≥50 m/s) , on the right, the SRV before plasma filtration was 47 m/s, after - 50 m/s (normal ≥50 m/s).

Example 3

Patient M., 31 years old, complains of intense headache upon admission. The last months in the frontotemporal region - a violation of sensorimotor sensitivity, a feeling of numbness in the occipital region, a memory impairment, a disturbance at night, episodic convulsions and trembling in the limbs at night, awakening at night and decreasing after moving the legs; on migrating pains in the abdomen; a decrease in the background of mood, a violation of speech by the type of "stuttering", increased aggressiveness and irritability; to reduce appetite; for unsteadiness when walking.

HISTORY OF DISEASE: He considers himself ill since childhood, was observed on an outpatient basis for chronic gastroduodenitis. Episodes of diarrhea are noted from youth, against the background of emotional stress. In 2006, he was examined and treated at the Central Research Institute of Human Resources with a diagnosis of chronic gastroduodenitis, DZHVP, no bowel examinations were performed, the patient independently took imodium with a positive effect. Since 2012, she has been observed for iron deficiency anemia. Since 2012, against the background of prolonged nervous stress, he has been experiencing frequent loose stools up to 6 r / d, periodically taking salofalk at 1 t x 2 r / d for 6 months as prescribed by a gastroenterologist on i / f. Since 2014, pain in the lower abdomen. In October 2010, where, according to the results of a biopsy from the post-bulb section of the 12 colon, celiac disease was detected, stage 3C according to Marsh.

Against the background of adherence to a gluten-free diet, the patient's state of health improved, abdominal pain decreased, and the stool returned to normal. Densitometry from 2014 osteoporosis. Densitometry from 01.2015 with positive dynamics. Since 2016, against the background of emotional stress, he has noted the appearance of speech disorders in the form of slow speech and stuttering, a persistent decrease in the background of mood, an increase in general weakness, increased headaches, and disturbed night sleep. Since January 2019, there has been an increase in the severity of the cephalgic syndrome, an increase in the severity of phobic and dyssomnic disorders.

PHYSICAL EXAMINATION: The position is active, the physique is correct, asthenic. The skin is pale pink in color, the visible mucous membranes are of normal color, the sclera is clean, the peripheral lymph nodes are not enlarged, elastic, painless. There are no edema. The musculoskeletal system is developed correctly. Respiratory organs: Complaints: no. Breathing through the nose is free. The chest is symmetrical, painless on palpation, elastic. With comparative percussion lung sound. With topographic percussion, the borders of the lungs are within the normal range. Auscultation revealed vesicular breathing, no wheezing. The number of respiratory movements is 18 in 1 min. Circulatory organs: Complaints: no. The area of the heart and large vessels of the neck is not visually changed. The apex beat is palpable in the 5th intercostal space, localized. Borders of relative cardiac dullness: upper III rib, left 0.5 cm medially from the mid-clavicular line, right 0.5 cm medially from the right edge of the sternum in the IV intercostal space. Rhythmic heart sounds, pulse = heart rate = 74 beats. min, BP pr. = lev. 100/70 mmHg Digestive organs: Complaints at the time of examination: see above. Appetite saved. Swallowing is not difficult, painless. The oral mucosa is pink, clean. The throat is clean, the tongue is moist, lined at the root with a white coating. The abdomen is symmetrical, postoperative scars, not swollen, actively involved in the act of breathing; on palpation, the abdomen is soft, sensitive in the umbilical region, along the colon. The liver is palpated along the edge of the costal arch. The spleen is not palpable. The pulsation of the abdominal aorta is preserved. Urinary organs. The area of the kidneys is not changed, the kidneys are not palpated. The bladder does not exit above the pubic symphysis. The effleurage symptom is negative on both sides. Endocrine system. Thyroid gland area of the thyroid gland is not changed, normal nutrition. Height 172 cm, Weight 45 kg, Temperature 36.7 °C.

NEUROLOGICAL STATUS: consciousness is clear, contact, oriented correctly in place, time and self. There are no meningeal symptoms. Brief mental status assessment scale 30 points. Hospital Anxiety and Depression Scale 14/12. The mood background is reduced. Astenized. Speech is changed according to a dysfunctional type, pronounces phrases and words with significant time delays, unevenly stretches and speeds up syllables. Signs of motor and sensory aphasia is determined. Cranial nerves: Sense of smell is not changed. Fields of view are not limited. Full eyeball movement. Pupils of medium size, S=D; palpebral fissures are not changed, S=D; direct and cross photoreactions are preserved, convergence is weakened, nystagmus. The face is symmetrical. Swallowing is not disturbed. Phonation saved. Tongue in the midline. Muscle tone is not changed, D=S. Muscle strength in the upper and lower limbs 5/5 points. Tendon reflexes are reduced, S=D. Performs coordinating tests (nose finger, heel-knee) with action tremor without passing by. Dysadiadochokinesis is absent. There is no dysmetria. There is slight staggering in Romberg's position. Pain, tactile and deep sensitivity are not changed. Motor-sensory axonal polyneuropathy associated with celiac disease. Secondary Restless Leg Syndrome. Pelvic functions are controlled. Walks on his own. Tension symptoms are negative.

LABORATORY AND INSTRUMENTAL INDICATORS:

CBC: Hemoglobin 11.7 (12.0-14.0) g/dl; Erythrocytes 3.62 (3.90-4.70) 10 ^∧ 6/µl; Wed hemoglobin content in erythrocytes 25.8 (27.0-31.0) pg; Average erythrocyte volume 75.1 (80.0-100.0) fl; Wed erythrocyte hemoglobin concentration 28.4 (30.0-38.0) g/dl; Hematocrit 44.0 (36.0-42.0) g/l; Platelets 157 (180-320) 10 ^∧ 3/µl; Average platelet volume 12.60 (7.40-12.00) fl; Leukocytes 3.57 (4.00-9.00) 10 ^∧ 9/l; Neutrophils 51.40 (48.00-78.00)%; Eosinophils 3.3 (0.5-5.0)%; Monocytes 8.6 (3.0-11.0)%; Lymphocytes 32.60 (19.00-37.00)%; Basophils 0.8 (0.0-1.0)%; Neutrophils abs. 1.84 (2.00-7.50) 10 ^∧ 9/l; Eosinophils abs. 0.12 (0.02-0.30) 10 ^∧ 9/l; Monocytes abs. 0.31 (0.09-0.60) 10 ^∧ 9/l; Abs. lymphocytes 1.16 (1.20-3.00) 10 ^∧ 9/l; Basophils abs. 0.03 (0.00-0.07) 10 ^∧ 9/l; Erythrocyte sedimentation rate according to Westergren 9 (0-20) mm/h;

Biochemical blood test: Total protein 63.2 (64.0-83.0) g/l; Albumin 32.9 (34.0-48.0) g/l; ALT 8.4 (7.0-35.0) U/l; ACT 21.4 (13.0-35.0) U/L; Bilirubin total 15.2 (5.0-21.0) µmol/l; Direct bilirubin 3.3 (0.0-3.4) µmol/l; Bilirubin indirect 11.9 (0.0-15.9) µmol/l; Glucose 4.11 (4.10-5.90) mmol/l; Creatinine 67 (53-97) µmol/l; Urea 3.02 (2.10-7.10) mmol/l; Potassium 3.88 (3.50-5.10) mmol/l;

Sodium 139.3 (136.0-145.0) mmol/l; Calcium total 2.53 (2.15-2.50) µmol/l; Iron 25.9 (9.0-30.4) µmol/l; Latent iron-binding capacity of serum 26.4 (27.8-53.7) µmol/l; Total iron-binding capacity of serum 55.3 (44.8-76.1) µmol/l; Triglycerides 0.77 (0.00-1.70) mmol/l; Total cholesterol 5.38 (0.00-5.18) mmol/l; HDL cholesterol 1.66 (1.04-1.55) mmol / l; Xc LDL 3.37 (2.85-3.37) mmol / l; Transferrin saturation coefficient with iron 46.9 (15.0-50.0)%; Gamma Glutamyltransferase 11 (0-38) U/l; Lactate dehydrogenase 147.6 (100.0-210.0) U/l; Alkaline phosphatase 45.4 (30.0-120.0) U/l; Uric acid 208.2 (155.0-357.0) µmol/l; C reactive protein 0.18 (0.00-5.00) mg/l;

EEG: Significant changes in the bioelectrical activity of the brain of a regulatory nature with increased ascending activating influences on the cortex. No typical forms of epiactivity were found.

ENMG: Slow conduction along the sensory fibers of both ulnar and median nerves. No pathology was found in the motor fibers.

NEUROLOGIST'S CONSULTATION

Main: Chronic sensorimotor polyneuropathy associated with gluten-sensitive celiac disease. Secondary Restless Leg Syndrome. Astheno-neurotic syndrome. Functional speech disorders. Chronic dyssomnia. Gluten ataxia, MR-spectroscopically confirmed.

Concomitant disease: Celiac disease, incomplete clinical remission. disaccharidase deficiency. Deficiency in body weight. Enteroptosis. Gastroesophageal reflux disease in the endoscopically negative stage. Chronic gastroduodenitis, not associated with Hp, moderate exacerbation. Biliary sludge. Functional hyperbilirubinemia. Gastroptosis Zet. Enteroptosis. Osteoporosis. Adenomyosis. AIT, euthyroidism. Thrombophilia.

The patient was on a gluten-free diet and took vitamin-mineral complexes.

The patient underwent 5 procedures of cascade plasma filtration. All procedures were well tolerated by the patient. During each cascade plasma filtration procedure, 1210 ml (80% VCP) of plasma was processed using the Evaflux 2A20 plasma filter. Replacement: 500 ml saline, 200 ml 20% albumin solution. The Evaflux™ Plasma Fractionator has a cylindrical plastic body with porous capillary membranes inside. The membrane material is a polymer of ethylene and vinyl alcohol. The total surface area of the membranes is 2 square meters. m. Filling volume of the filter (free volume) - 140 ml, the filter is filled with sterile pyrogen-free water. The Evaflux 2A20 filter has a pore size of 20 nm, which is recommended by the manufacturer for autoimmune diseases. It is recommended to repeat the course of treatment every 3 months for 2 years.

After the treatment, the neurological status clinically shows positive dynamics in the form of an increase in pain sensitivity in the distal lower extremities, regression of the restless legs syndrome, and a decrease in the severity of ataxia.

According to the stimulation electroneuromyography of the sensory fibers of the distal nerves of the upper extremities, the dynamics of recovery of the excitation propagation velocity (ESV) is noted: in the median nerve on the left, the SVV was 42 m/s before plasma filtration, after - 47 m/s (normal ≥50 m/s), on the right SV before plasma filtration was 39 m/s, after - 45 m/s (normal ≥50 m/s), in the ulnar nerve on the left SRV before plasma filtration was 43 m/s, after - 48 m/s (normal ≥50 m/s) , on the right, SRV before plasma filtration was 39 m/s, after - 44 m/s (normal ≥50 m/s).

Polyneuropathy associated with gluten-sensitive celiac disease was treated in 7 patients. The effectiveness of the proposed method was confirmed in all cases - reducing the manifestations of sensory polyneuropathy associated with gluten-sensitive celiac disease.

Information sources

1 - Balabolkin M.I., Kreminskaya V.M. Diabetic polyneuropathy. Journal of Neurology and Psychiatry. Korsakov. - 2000. - No. 10. - With. 67-74

2 - Strokov I.A., Barinov A.N. Clinic, pathogenesis and treatment of pain in diabetic polyneuropathy. Neurological journal. - 2001, No. 6, p. 47-54.

Claims (1)

A method for the treatment of polyneuropathy associated with gluten-sensitive celiac disease, including a gluten-free diet, replenishment of vitamin and mineral deficiencies, characterized in that cascade plasma filtration is additionally carried out with filters with a pore size of 10-12 nm when using 4-5 procedures in 1-2 days with a repetition of the course of treatment every 3-4 months for 2-3 years.