This case takes place in Missouri and involves a patient who on presented to a neurologist with complaints of numbness, pins and needles, and burning on the bottom of the feet. The patient was diagnosed with polyneuropathy by the defending physician on that visit. Eight months later, the physician prescribed the patient intravenous immunoglobulin therapy, the indication for which was demyelinating peripheral neuropathy. Over the course of the eight months after the initial visit, the physician’s diagnosis of the plaintiff’s condition reportedly continued to be polyneuropathy, for which he prescribed oral medications as well as IVIg therapy, which the plaintiff continued to undergo on a monthly basis. Up until that point, the patient’s condition had not improved and instead, had gradually worsened so the physician abruptly discontinued IVIg treatment without weaning the patient off it. The patient is now suffering from serious and permanent injuries including numbness and tingling, pain and weakness in both lower extremities, unsteady gait, tremors, fall, fatigue, malaise, and difficulty sleeping. The patient alleges this was caused by the physician failing to diagnose the patient’s condition in addition to properly monitoring and treating the condition.
Question(s) For Expert Witness
- 1. How often do you treat patients with this condition?
- 2. What are the indications for IVIG therapy?
Expert Witness Response E-008800
My specialty is diseases of nerves and muscles and most of the patients I see have peripheral neuropathy. My current practice is currently limited to the Amyloidosis Group at Boston University where I see patients with amyloid polyneuropathy. Prior to this, I spent 16 years practicing neurology with a concentration of patients with neuropathy, performing Nerve Conduction Studies and Electromyography (EMG). The current indications for IVIG therapy in neurological disease, as put forth by the American Academy of Neurology are: Guillain-Barre Syndrome, Chronic Inflammatory Demyelinating Polyneuropathy, Myasthenia Gravis Multi-Focal Motor Neuropathy with Conduction Block. Please see https://www.aan.com/Guidelines/Home/GetGuidelineContent/528. I have used IVIG for the treatment of Guillain-Barre syndrome, Chronic Inflammatory Demyelinating Polyneuropathy, Multifocal Motor Neuropathy and Myasthenia Gravis. These diagnoses are not common and so I have only treated dozens of patients over the years, not hundreds. It is my opinion that Neurologists who are not at a specialized center and who claim to have used IVIG in hundreds of patients are likely using the drug incorrectly. IVIG is not typically weaned. It is typically used for a defined amount of time and then stopped. Rarely, it is used chronically. Over the years I have seen IVIG used incorrectly in people who have axonal neuropathy, as opposed to demyelinating neuropathy. In axonal neuropathy, it is the axon itself (the arm-like extension of the nerve cell body (neuron)) that is damaged. In demyelinating neuropathy, it is the fatty insulating coating that surrounds the axon (myelin) that is damaged. Occasionally, both the axon and the myelin are damaged. This is seen most commonly in people with diabetes mellitus. The first step in a case like this is to review her initial evaluation note and the raw data from her initial Nerve Conduction Studies and EMG in order to determine if she has neuropathy and if so, what sort it is.