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Ahmed GK, Karim AA, Khedr EM, Elbeh K, Moheb A, Abokresha M, Haridy NA. Case report: Avoidant/restrictive food intake disorder after tonsillectomy. Front Psychiatry 2024; 15:1351056. [PMID: 38993387 PMCID: PMC11237393 DOI: 10.3389/fpsyt.2024.1351056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/29/2024] [Indexed: 07/13/2024] Open
Abstract
Background Avoidant Restrictive Food Intake Disorder (ARFID) is a newly classified eating disorder that requires further understanding of its presentation. There is no previous report of ARFID in a child post-tonsillectomy. ARFID may be a potential negative outcome for children following oropharyngeal surgery. Case presentation A female child aged 10 years and 2 months presented with ARFID associated with depression, anxiety and nutritional deficiency following tonsillectomy. She had more difficulty in swallowing solids than fluids and had repeated vomiting and spitting food after chewing it. She became dehydrated and malnourished with a BMI of 10.5 and was misdiagnosed with myasthenic gravis. Conclusions To our knowledge, this is the first case report of ARFID in a child post-tonsillectomy. We discuss the pathophysiology of ARFID, which remains elusive, and recommend psychiatric assessment when evaluating children post operative tonsillectomy.
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Affiliation(s)
- Gellan K. Ahmed
- Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Ahmed A. Karim
- Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Eman M. Khedr
- Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Khaled Elbeh
- Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Amira Moheb
- Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Marwa Abokresha
- Department of Internal Medicine, Gastroenterology Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Nourelhoda A. Haridy
- Department of Neurology and Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt
- Department of Neuromuscular Disorders, University College London (UCL) Institute of Neurology, London, United Kingdom
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2
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Winther JB, Morgen JJ, Skov M, Broch-Lips MG, Nielsen OB, Overgaard K, Pedersen TH. Role of recovery of acetylcholine release in compromised neuromuscular junction function. Neuromuscul Disord 2024; 36:48-59. [PMID: 38359767 DOI: 10.1016/j.nmd.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/17/2023] [Accepted: 01/22/2024] [Indexed: 02/17/2024]
Abstract
Everyday physical activities, such as walking, are enabled by repeated skeletal muscle contractions and require a well-functioning neuromuscular transmission. In myasthenic disorders, activities of daily living are debilitated by a compromised neuromuscular transmission leading to muscle weakness and fatiguability in patients. To enable physical activity, acetylcholine (ACh) is released repeatedly from the motor nerve, however, the role of the nerve terminals' capacity to sustain ACh release to support repetitive contractions under compromised neuromuscular transmission remains unclear. To explore this, we studied synaptic and contractile function during repeated contractions in healthy rat skeletal muscles under conditions of pharmacological induced compromised neuromuscular transmission. Using recordings of endplate potentials, compound muscle action potential (CMAP) and force production in isolated skeletal muscles and living, anesthetized animals, we found that force and CMAP were markedly reduced by even very light activity performed up to 5 s prior to contraction showing that recovery of ACh release was insufficient to maintain synaptic transmission strength. Our results suggest that the timing of depletion and restoration of ACh release may impact clinical signs of weakness and fatigability in patients with impaired neuromuscular transmission and affect the sensitivity of electromyographic recordings in the clinic.
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Affiliation(s)
| | | | - Martin Skov
- NMD Pharma A/S, Palle Juul-Jensens Blvd. 82, 8200 Aarhus N, Denmark
| | | | - Ole Bækgaard Nielsen
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark
| | - Kristian Overgaard
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark
| | - Thomas Holm Pedersen
- NMD Pharma A/S, Palle Juul-Jensens Blvd. 82, 8200 Aarhus N, Denmark; Department of Biomedicine, Aarhus University, Ole Worms Allé 4, 8000 Aarhus C, Denmark.
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Simula ER, Zarbo IR, Arru G, Sechi E, Meloni R, Deiana GA, Solla P, Sechi LA. Antibody Response to HERV-K and HERV-W Envelope Epitopes in Patients with Myasthenia Gravis. Int J Mol Sci 2023; 25:446. [PMID: 38203616 PMCID: PMC10778599 DOI: 10.3390/ijms25010446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/20/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
Myasthenia gravis is an antibody-mediated autoimmune neurological disorder characterized by impaired neuromuscular junction transmission, resulting in muscle weakness. Recently, the involvement of Human Endogenous Retroviruses (HERVs) in the pathophysiology of different immune-mediated and neurodegenerative diseases, such as multiple sclerosis, has been demonstrated. We aimed to investigate potential immune system involvement related to humoral responses targeting specific epitopes of HERV-K and HERV-W envelope proteins in myasthenia gravis. Myasthenia gravis patients were recruited in the Neurology Unit, while healthy controls were selected from the Blood Transfusion Center, both affiliated with AOU Sassari. Highly immunogenic antigens of HERV-K and HERV-W envelope proteins were identified using the Immune Epitope Database (IEDB) online tool. These epitopes were utilized in enzyme-linked immunosorbent assays (ELISA) to detect autoantibodies in serum directed against these sequences. The study involved 39 Healthy Donors and 47 MG patients, further categorized into subgroups based on the presence of autoantibodies: MG-AchR Ab+ (n = 17), MG-MuSK Ab+ (n = 7), double seronegative patients (MG-DSN, n = 18), MG-LRP4 Ab + (n = 4), and one patient with no antibodies data (n = 1). Our findings revealed high levels of autoantibodies in myasthenia gravis patients directed against the HERV-K-env-su(19-37), HERV-K-env-su(109-126), HERV-K-env-su(164-186), HERV-W-env(93-108), HERV-W-env(129-14), and HERV-W-env(248-262) epitopes. Notably, these results remained highly significant even when patients were subdivided into MG-AchR Ab+ and MG-DSN subgroups. Correlation analysis further revealed significant positive associations between the antibody levels against HERV-K and HERV-W families in patients, suggesting a synergistic action of the two HERVs in the pathology context since this correlation is absent in the control group. This study marks the first identification of a specific humoral response directed against defined epitopes of HERV-K and HERV-W envelope proteins in myasthenia gravis patients. These findings lay the foundation for future investigations aimed at elucidating the molecular mechanisms driving this immune response. The detection of these autoantibodies suggests the potential for novel biomarkers, especially within the MG-DSN patient subgroup, addressing the need for new biomarkers in this population.
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Affiliation(s)
- Elena Rita Simula
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro 43b, 07100 Sassari, Italy;
| | - Ignazio Roberto Zarbo
- Department of Medicine, Surgery and Pharmacy University of Sassari, Viale S. Pietro 10, 07100 Sassari, Italy; (I.R.Z.); (G.A.); (E.S.); (R.M.); (G.A.D.)
| | - Giannina Arru
- Department of Medicine, Surgery and Pharmacy University of Sassari, Viale S. Pietro 10, 07100 Sassari, Italy; (I.R.Z.); (G.A.); (E.S.); (R.M.); (G.A.D.)
| | - Elia Sechi
- Department of Medicine, Surgery and Pharmacy University of Sassari, Viale S. Pietro 10, 07100 Sassari, Italy; (I.R.Z.); (G.A.); (E.S.); (R.M.); (G.A.D.)
| | - Rossella Meloni
- Department of Medicine, Surgery and Pharmacy University of Sassari, Viale S. Pietro 10, 07100 Sassari, Italy; (I.R.Z.); (G.A.); (E.S.); (R.M.); (G.A.D.)
- Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy
| | - Giovanni Andrea Deiana
- Department of Medicine, Surgery and Pharmacy University of Sassari, Viale S. Pietro 10, 07100 Sassari, Italy; (I.R.Z.); (G.A.); (E.S.); (R.M.); (G.A.D.)
| | - Paolo Solla
- Department of Medicine, Surgery and Pharmacy University of Sassari, Viale S. Pietro 10, 07100 Sassari, Italy; (I.R.Z.); (G.A.); (E.S.); (R.M.); (G.A.D.)
| | - Leonardo Antonio Sechi
- Department of Biomedical Sciences, University of Sassari, Viale San Pietro 43b, 07100 Sassari, Italy;
- Struttura Complessa Microbiologia e Virologia, Azienda Ospedaliera Universitaria, 07100 Sassari, Italy
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Kouyoumdjian JA, Estephan EDP. Electrophysiological evaluation of the neuromuscular junction: a brief review. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:1040-1052. [PMID: 38157872 PMCID: PMC10756823 DOI: 10.1055/s-0043-1777749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024]
Abstract
The nerve terminal and muscle membrane compose the neuromuscular junction. After opening the voltage-gated calcium channels, action potentials from the motor axons provoke a cascade for the acetylcholine release from synaptic vesicles to the synaptic cleft, where it binds to its receptor at the muscle membrane for depolarization. Low amplitude compound muscle action potential typically presents in presynaptic disorders, increasing by more than 100% after a 10-second effort in the Lambert-Eaton myasthenic syndrome and less in botulism. Needle electromyography may show myopathic motor unit action potentials and morphological instability ("jiggle") due to impulse blocking. Low-frequency repetitive nerve stimulation (RNS) is helpful in postsynaptic disorders, such as myasthenia gravis and most congenital myasthenic syndromes, where the number of functioning acetylcholine receptors is reduced. Low-frequency RNS with a decrement >10% is abnormal when comparing the 4th to the first compound muscle action potential amplitude. High-frequency RNS is helpful in presynaptic disorders like Lambert-Eaton myasthenic syndrome, botulism, and some rare congenital myasthenic syndromes. The high-frequency RNS releases more calcium, increasing the acetylcholine with a compound muscle action potential increment. Concentric needle records apparent single-fiber action potentials (spikes). A voluntary activation measures the jitter between spikes from two endplates. An electrical activation measures the jitter of one spike (one endplate). The jitter is the most sensitive test for detecting a neuromuscular junction dysfunction. Most neuromuscular junction disorders are responsive to treatment.
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Affiliation(s)
- João Aris Kouyoumdjian
- Faculdade de Medicina de São José do Rio Preto, Departamento de Ciências Neurológicas, Psiquiatria e Psicologia Médica, São José do Rio Preto SP, Brazil.
| | - Eduardo de Paula Estephan
- Faculdade de Medicina de São José do Rio Preto, Departamento de Ciências Neurológicas, Psiquiatria e Psicologia Médica, São José do Rio Preto SP, Brazil.
- Universidade de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.
- Faculdade de Medicina Santa Marcelina, São Paulo SP, Brazil.
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Lambert-Eaton Myasthenic Syndrome in Lung Cancer. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:3912376. [PMID: 35854773 PMCID: PMC9277170 DOI: 10.1155/2022/3912376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/16/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022]
Abstract
The aim is to study lung cancer with Lambert-Eaton myasthenic syndrome (LEMS) with clinical and electrical characteristics of physiology and prognosis. Fourteen LEMS patients with lung cancer were studied retrospectively. The data including demographics, clinical presentation, treatments, and prognosis from the medical records were analyzed. Lung cancer coexisting with LEMS is more common in men (10/14). The median age was 67.1 years. Eleven (78.6%) patients experienced gradual onset of disease. Most patients presented nervous system lesions prior to occult tumors. The most common symptoms reported were proximal muscle weakness (92.9%), decreased or absent tendon reflexes (50%), and autonomic dysfunction (71.4%). All the patients showed reduction in action potential amplitude after repetitive peripheral never stimulation at low frequency and increased amplitude at high frequency. LEMS usually occurs prior to lung cancer with complicated and various clinical manifestations in our centers. We should improve awareness and knowledge of such disease to shorten the diagnostic delay and lead to few misdiagnoses.
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6
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Kang L, Wan C. Paraneoplastic syndrome in neuroophthalmology. J Neurol 2022; 269:5272-5282. [PMID: 35779086 DOI: 10.1007/s00415-022-11247-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/19/2022] [Accepted: 06/19/2022] [Indexed: 12/16/2022]
Abstract
Paraneoplastic syndrome is a group of clinical symptoms that occur in the state of systemic malignant tumors. Paraneoplastic syndrome of the nervous system can affect any part of the central and peripheral nervous system and may also affect the eyes. In neuroophthalmology, paraneoplastic syndrome has a variety of manifestations that can affect both the afferent and efferent visual systems. The afferent system may involve the optic nerve, retina and uvea; the efferent system may involve eye movement, neuromuscular joints or involuntary eye movements and pupil abnormalities and may also have other neurological symptoms outside the visual system. This article discusses the clinical manifestations, pathological mechanisms, detection methods and treatment methods of paraneoplastic syndrome in neuroophthalmology. The performance of paraneoplastic syndrome is diverse, the diagnosis is difficult, and the treatment should be considered systematically. Differential diagnosis, optimal evaluation and management of these manifestations is not only the key to treatment but also a challenge.
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Affiliation(s)
- Longdan Kang
- Department of Ophthalmology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China
| | - Chao Wan
- Department of Ophthalmology, The First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, China.
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7
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De León AM, Harrison TB, Garcia-Santibanez R. Update on Paraneoplastic Neuromuscular Disorders. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00722-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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8
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Cheng K, Wang Y, Zhou Y, Xia R, Tang L, Liu J. Neurological Adverse Events Induced by Immune Checkpoint Inhibitors in Non-Small Cell Lung Cancer: Current Perspectives and New Development. Clin Med Insights Oncol 2021; 15:11795549211056261. [PMID: 34866959 PMCID: PMC8637700 DOI: 10.1177/11795549211056261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/10/2021] [Indexed: 02/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of multiple malignancies, especially in non-small cell lung cancer (NSCLC). With the extensive application of ICIs in clinical practice, clinicians have to manage their toxicities, which are often termed immune-related adverse events (irAEs). Several ICIs, such as nivolumab, pembrolizumab, atezolizumab, and durvalumab, have been approved by the US Food and Drug Administration (FDA) to treat advanced NSCLC, accompanied by a broad spectrum of toxicity reactions. However, ICIs-associated neurological toxicities, regarding polyneuropathy, Bell palsy, encephalopathy, and myasthenia gravis, as uncommon emerging toxicities have not been well recognized, present a challenge for clinicians to improve awareness of supervision, recognition, and management before death from them. Herein, we have summarized the incidence, diagnosis, clinical manifestations, potential mechanisms, treatments, and outcomes of ICIs-related neurotoxicity and optimized the management approach for NSCLC patients. Prompt recognition and proper management are indispensable to reduce the morbidity of these patients with immune-related neurological toxicities.
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Affiliation(s)
- Ke Cheng
- Department of Abdominal Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yuqing Wang
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Yuwen Zhou
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Ruolan Xia
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Liansha Tang
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Jiyan Liu
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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Payedimarri AB, Ratti M, Rescinito R, Vasile A, Seys D, Dumas H, Vanhaecht K, Panella M. Development of a Model Care Pathway for Myasthenia Gravis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11591. [PMID: 34770107 PMCID: PMC8582978 DOI: 10.3390/ijerph182111591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/29/2021] [Accepted: 10/31/2021] [Indexed: 12/21/2022]
Abstract
Myasthenia Gravis (MG) is a chronic, life-lasting condition that requires high coordination among different professionals and disciplines. The diagnosis of MG is often delayed and sometimes misdiagnosed. The goal of the care pathway (CP) is to add value to healthcare reducing unnecessary variations. The quality of the care received by patients affected with MG could benefit from the use of CP. We conducted a study aimed to define an inclusive, comprehensive, and multidisciplinary CP for the diagnosis, treatment, and care of MG. The development of the model CP, key interventions, and process indicators is based on the literature review and 85 international MG experts were involved in their evaluation, expressing a judgment of relevance through the Delphi study. 60 activities are included in the model CP and evaluated by the MG experts were valid and feasible. The 60 activities were then translated into 14 key interventions and 24 process indicators. We believe that the developed model CP will help for MG patients to have a timely diagnosis and high-quality, accessible, and cost-effective treatments and care. We also believe that the development of model CPs for other rare diseases is feasible and could aid in the integration of evidence-based knowledge into clinical practice.
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Affiliation(s)
- Anil babu Payedimarri
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Matteo Ratti
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Riccardo Rescinito
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Alessandra Vasile
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Deborah Seys
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, 3000 Leuven, Belgium
| | | | - Kris Vanhaecht
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, 3000 Leuven, Belgium
- Department of Quality Management, University Hospitals Leuven, University of Leuven, 3000 Leuven, Belgium
| | - Massimiliano Panella
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
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Warnecke T, Im S, Labeit B, Zwolinskaya O, Suntrup-Krüger S, Oelenberg S, Ahring S, Schilling M, Meuth S, Melzer N, Wiendl H, Ruck T, Dziewas R. Detecting myasthenia gravis as a cause of unclear dysphagia with an endoscopic tensilon test. Ther Adv Neurol Disord 2021; 14:17562864211035544. [PMID: 34394727 PMCID: PMC8361548 DOI: 10.1177/17562864211035544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/10/2021] [Indexed: 11/17/2022] Open
Abstract
Aims: The flexible endoscopic evaluation of swallowing-tensilon test (FTT) was developed to diagnose myasthenia gravis (MG) in patients with unclear pharyngeal dysphagia. The purpose of this study was to determine sensitivity and specificity of the FTT and compare its diagnostic validity with that of other diagnostic markers. Methods: In this single-centre pragmatic clinical cohort study, a total of 100 patients with unclear pharyngeal dysphagia were eligible to undergo FTT. All patients were subjected to FTT and subsequently followed up clinically. FTT was considered positive if a significant improvement of pharyngeal swallowing function could be objectified endoscopically upon administration of edrophonium chloride. In addition, repetitive nerve stimulation test and serum MG antibody analysis were conducted. Results: All subjects (mean age 62.5 ± 14.1 years, female 33) underwent FTT without any complications. According to the results of the diagnostic procedures and based on long-term clinical follow-up for at least 3 years, 51 patients were finally diagnosed with MG. The sensitivity and specificity for the FTT was 88.2% and 95.9%, respectively. Application of the Cochran’s Q test showed statistically significant heterogeneity among the diagnostic tests, with results indicating FTT performance to be more accurate than the repetitive nerve stimulation results (p < 0.001) and comparable with serum antibody tests (p > 0.99). Conclusion: FTT has excellent clinical properties to be used routinely in the assessment of dysphagia with isolated or predominant pharyngeal muscle involvement allowing rapid and accurate diagnosis of MG.
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Affiliation(s)
- Tobias Warnecke
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Albert-Schweitzer-Campus 1, Building A1, Münster, 48149, Germany
| | - Sun Im
- Department of Rehabilitation Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bendix Labeit
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Olga Zwolinskaya
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Sonja Suntrup-Krüger
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Stephan Oelenberg
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Sigrid Ahring
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Matthias Schilling
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Sven Meuth
- Department of Neurology, Heinrich-Heine University of Duesseldorf, Duesseldorf, Germany
| | - Nico Melzer
- Department of Neurology, Heinrich-Heine University of Duesseldorf, Duesseldorf, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Muenster, Muenster, Germany
| | - Tobias Ruck
- Department of Neurology, Heinrich-Heine University of Duesseldorf, Duesseldorf, Germany
| | - Rainer Dziewas
- Department of Neurology and Neurorehabilitation, Hospital Osnabrueck, Osnabrueck, Germany
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Moron H, Gagnard-Landra C, Guiraud D, Dupeyron A. Contribution of Single-Fiber Evaluation on Monitoring Outcomes Following Injection of Botulinum Toxin-A: A Narrative Review of the Literature. Toxins (Basel) 2021; 13:toxins13050356. [PMID: 34067540 PMCID: PMC8156529 DOI: 10.3390/toxins13050356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 11/24/2022] Open
Abstract
Botulinum toxin-A (BoNT-A) blocks acetylcholine release at the neuromuscular junction (NMJ) and is widely used for neuromuscular disorders (involuntary spasms, dystonic disorders and spasticity). However, its therapeutic effects are usually measured by clinical scales of questionable validity. Single-fiber electromyography (SFEMG) is a sensitive, validated diagnostic technique for NMJ impairment such as myasthenia. The jitter parameter (µs) represents the variability of interpotential intervals of two muscle fibers from the same motor unit. This narrative review reports SFEMG use in BoNT-A treatment. Twenty-four articles were selected from 175 eligible articles searched in Medline/Pubmed and Cochrane Library from their creation until May 2020. The results showed that jitter is sensitive to early NMJ modifications following BoNT-A injection, with an increase in the early days’ post-injection and a peak between Day 15 and 30, when symptoms diminish or disappear. The reappearance of symptoms accompanies a tendency for a decrease in jitter, but always precedes its normalization, either delayed or nonexistent. Increased jitter is observed in distant muscles from the injection site. No dose effect relationship was demonstrated. SFEMG could help physicians in their therapeutic evaluation according to the pathology considered. More data are needed to consider jitter as a predictor of BoNT-A clinical efficacy.
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Affiliation(s)
- Hélène Moron
- Department of Functional Exploration of the Nervous System and Acupuncture, CHU Nîmes, Univ Montpellier, 30029 Nîmes, France;
- EuroMov DHM, IMT Ales, Univ Montpellier, 34090 Montpellier, France;
- CAMIN, INRIA, Univ Montpellier, 34090 Montpellier, France;
- Correspondence:
| | - Corine Gagnard-Landra
- Department of Functional Exploration of the Nervous System and Acupuncture, CHU Nîmes, Univ Montpellier, 30029 Nîmes, France;
| | - David Guiraud
- CAMIN, INRIA, Univ Montpellier, 34090 Montpellier, France;
| | - Arnaud Dupeyron
- EuroMov DHM, IMT Ales, Univ Montpellier, 34090 Montpellier, France;
- Department of Physical and Rehabilitation Medicine, CHU Nîmes, Univ Montpellier, 30029 Nîmes, France
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Rousseff RT. Diagnosis of Myasthenia Gravis. J Clin Med 2021; 10:jcm10081736. [PMID: 33923771 PMCID: PMC8073361 DOI: 10.3390/jcm10081736] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 11/24/2022] Open
Abstract
The diagnosis of autoimmune Myasthenia Gravis (MG) remains clinical and rests on the history and physical findings of fatigable, fluctuating muscle weakness in a specific distribution. Ancillary bedside tests and laboratory methods help confirm the synaptic disorder, define its type and severity, classify MG according to the causative antibodies, and assess the effect of treatment objectively. We present an update on the tests used in the diagnosis and follow-up of MG and the suggested approach for their application.
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Affiliation(s)
- Rossen T. Rousseff
- Department of Neurology, Ibn-Sina Hospital, Sabah Health Area,, Kuwait City 13115, Kuwait; ; Tel.: +359-878-417-412
- Science and Research Institute, Medical University of Pleven, 5800 Pleven, Bulgaria
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Kouyoumdjian JA, Paiva GP, Stålberg E. Concentric Needle Jitter in 97 Myasthenia Gravis Patients. Front Neurol 2020; 11:600680. [PMID: 33281737 PMCID: PMC7691317 DOI: 10.3389/fneur.2020.600680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 10/13/2020] [Indexed: 11/24/2022] Open
Abstract
Objectives: To estimate the jitter parameters (single-fiber electromyography) in myasthenia gravis patients mostly by electrical activation in Frontalis, Orbicularis Oculi, and Extensor Digitorum muscles using a concentric needle electrode. Methods: Between 2009 and 2019, a total of 97 myasthenia gravis patients, 52 male, and mean age 54 years were included. Results: Any abnormal jitter parameter in individual muscles was 90.5% (Frontalis), 88.5% (Orbicularis Oculi), and 86.6% (Extensor Digitorum). Any jitter parameter combining Orbicularis Oculi and Frontalis muscle was abnormal in 100% for the ocular, and in 92.9% for the generalized myasthenia gravis. The most abnormal muscle was Orbicularis Oculi for the generalized, and Frontalis for the ocular myasthenia gravis. The decrement was abnormal in 78.4%, 85.9% for the generalized, and 25% for the ocular myasthenia gravis. The mean jitter ranged from 14.2 to 86 μs (mean 33.3 μs) for the ocular myasthenia gravis and from 14.4 to 220.4 μs (mean 66.3 μs) for the generalized myasthenia gravis. The antibody titers tested positive in 86.6%, 91.8% for the generalized, and 50% for the ocular myasthenia gravis. Thymectomy was done in 48.5%, thymoma was found in 19.6%, and myasthenic crisis occurred by 21.6%. Conclusion: The jitter parameters achieved a 100% abnormality in ocular myasthenia gravis if both the Orbicularis Oculi and Frontalis muscles were tested. There was a high jitter abnormality in generalized myasthenia gravis cases with one muscle tested, with about a 2% increase in sensitivity when a second is added. Concentric needle electrode jitter had high sensitivity similar to the single fiber electrode (93.8%), followed by antibody titers (86.6%), and abnormal decrement (78.4%).
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Affiliation(s)
- João Aris Kouyoumdjian
- Laboratório Investigação Neuromuscular, Faculdade Estadual Medicina São José do Rio Preto, São Paulo, Brazil
| | - Gabriel Pina Paiva
- Laboratório Investigação Neuromuscular, Faculdade Estadual Medicina São José do Rio Preto, São Paulo, Brazil
| | - Erik Stålberg
- Department of Clinical Neurophysiology, Institute of Neurosciences, Uppsala University, Uppsala, Sweden
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Abstract
Even if nerves and muscles are the principal targets of intensive care unit-acquired weakness, the neuromuscular junction may be as well involved. In intensive care units, neuromuscular blocking agents are classically used, and side effects are possible. Sepsis, immobilization, and denervation which are common in intensive care units may be the cause of neuromuscular junction disorders and participate to the pathophysiology of weakness. We propose here a review of end-plate disorders in intensive care units to highlight their mechanisms and propose diagnosis tools.
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15
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Lung cancer prediction in Lambert-Eaton myasthenic syndrome in a prospective cohort. Sci Rep 2020; 10:10546. [PMID: 32601396 PMCID: PMC7324357 DOI: 10.1038/s41598-020-67571-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 06/08/2020] [Indexed: 11/22/2022] Open
Abstract
To evaluate the Dutch-English Lambert-Eaton Myasthenic Syndrome (LEMS) Tumour Association Prediction (DELTA-P) score in a prospective cohort of patients with newly diagnosed LEMS to assess the clinical validity of this tool in a real-world setting. Clinical features from 87 patients with LEMS, occurring within three months from disease onset, were collated to produce a DELTA-P score for each patient. Lung cancer was detected in 44/87 (51%) LEMS patients. Weight loss ≥ 5%, tobacco use at LEMS onset and age at onset ≥ 50 years were independent predictors for the development of small-cell lung cancer (SCLC) in LEMS patients in multivariable analysis. Median DELTA-P scores were significantly higher in SCLC-LEMS patients (3.5, 95% CI 3 to 4) compared to non-tumour-LEMS (2, 95% CI 1 to 2) (P < 0.0001). Higher DELTA-P scores increased the risk of SCLC stepwise (score 0 = 0%, 1 = 18.8%, 2 = 45%, 3 = 55.5%, 4 = 85.7%, 5 = 87.5%, 6 = 100%). The area under the curve of the receiver operating curve was 82.5% (95% CI 73.9% to 91%). The DELTA-P cancer prediction score, calculated at the time of LEMS diagnosis, is an effective tool for cancer screening in an independent, prospective study setting.
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16
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de Meel RHP, Keene KR, Wirth MA, Weber KP, Badrising UA, Verschuuren JJ, Tannemaat MR. Repetitive ocular vestibular evoked myogenic potentials in myasthenia gravis. Neurology 2020; 94:e1693-e1701. [PMID: 32217778 DOI: 10.1212/wnl.0000000000009306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 10/29/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To validate the repetitive ocular vestibular evoked myogenic potentials (RoVEMP) test for diagnostic use in myasthenia gravis (MG) and to investigate its value in diagnostically challenging subgroups. METHODS The RoVEMP test was performed in 92 patients with MG, 22 healthy controls, 33 patients with a neuromuscular disease other than MG (neuromuscular controls), 4 patients with Lambert-Eaton myasthenic syndrome, and 2 patients with congenital myasthenic syndrome. RESULTS Mean decrement was significantly higher in patients with MG (28.4% ± 32.2) than in healthy controls (3.2% ± 13.9; p < 0.001) or neuromuscular controls (3.8% ± 26.9; p < 0.001). With neuromuscular controls as reference, a cutoff of ≥14.3% resulted in a sensitivity of 67% and a specificity of 82%. The sensitivity of the RoVEMP test was 80% in ocular MG and 63% in generalized MG. The RoVEMP test was positive in 6 of 7 patients with seronegative MG (SNMG) with isolated ocular weakness. Of 10 patients with SNMG with negative repetitive nerve stimulation (RNS) results, 73% had an abnormal RoVEMP test. The magnitude of decrement was correlated with the time since the last intake of pyridostigmine (B = 5.40; p = 0.019). CONCLUSIONS The RoVEMP test is a new neurophysiologic test that, in contrast to RNS and single-fiber EMG, is able to measure neuromuscular transmission of extraocular muscles, which are the most affected muscles in MG. Especially in diagnostically challenging patients with negative antibody tests, negative RNS results, and isolated ocular muscle weakness, the RoVEMP test has a clear added value in supporting the diagnosis of MG. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that RoVEMP distinguishes MG from other neuromuscular diseases.
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Affiliation(s)
- Robert H P de Meel
- From the Department of Neurology (R.H.P.d.M., K.R.K., U.A.B, J.J.V., M.R.T.), Leiden University Medical Center, the Netherlands; and Departments of Ophthalmology (M.A.W., K.P.W.) and Neurology (K.P.W.), University Hospital Zurich, University of Zurich, Switzerland
| | - Kevin R Keene
- From the Department of Neurology (R.H.P.d.M., K.R.K., U.A.B, J.J.V., M.R.T.), Leiden University Medical Center, the Netherlands; and Departments of Ophthalmology (M.A.W., K.P.W.) and Neurology (K.P.W.), University Hospital Zurich, University of Zurich, Switzerland
| | - Magdalena A Wirth
- From the Department of Neurology (R.H.P.d.M., K.R.K., U.A.B, J.J.V., M.R.T.), Leiden University Medical Center, the Netherlands; and Departments of Ophthalmology (M.A.W., K.P.W.) and Neurology (K.P.W.), University Hospital Zurich, University of Zurich, Switzerland
| | - Konrad P Weber
- From the Department of Neurology (R.H.P.d.M., K.R.K., U.A.B, J.J.V., M.R.T.), Leiden University Medical Center, the Netherlands; and Departments of Ophthalmology (M.A.W., K.P.W.) and Neurology (K.P.W.), University Hospital Zurich, University of Zurich, Switzerland
| | - Umesh A Badrising
- From the Department of Neurology (R.H.P.d.M., K.R.K., U.A.B, J.J.V., M.R.T.), Leiden University Medical Center, the Netherlands; and Departments of Ophthalmology (M.A.W., K.P.W.) and Neurology (K.P.W.), University Hospital Zurich, University of Zurich, Switzerland
| | - Jan J Verschuuren
- From the Department of Neurology (R.H.P.d.M., K.R.K., U.A.B, J.J.V., M.R.T.), Leiden University Medical Center, the Netherlands; and Departments of Ophthalmology (M.A.W., K.P.W.) and Neurology (K.P.W.), University Hospital Zurich, University of Zurich, Switzerland
| | - Martijn R Tannemaat
- From the Department of Neurology (R.H.P.d.M., K.R.K., U.A.B, J.J.V., M.R.T.), Leiden University Medical Center, the Netherlands; and Departments of Ophthalmology (M.A.W., K.P.W.) and Neurology (K.P.W.), University Hospital Zurich, University of Zurich, Switzerland.
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Maddison P, Gozzard P, Sadalage G, Ambrose PA, Chapman CJ, Murray A, Thomsen S, Berretta A, Lang B. Neuronal antibody detection and improved lung cancer prediction in Lambert-Eaton myasthenic syndrome. J Neuroimmunol 2020; 340:577149. [PMID: 31951874 DOI: 10.1016/j.jneuroim.2020.577149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/09/2020] [Accepted: 01/09/2020] [Indexed: 10/25/2022]
Abstract
Since approximately 50% of patients with Lambert-Eaton myasthenic syndrome (LEMS) subsequently develop small-cell lung cancer (SCLC), it is important to be able to predict cancer occurrence in these patients at neurological presentation. We aimed to determine whether circulating biomarkers were effective and objective predictors of cancer development in LEMS. We found that the presence of either SOX2, N-type voltage gated calcium channel or GABAb antibodies at LEMS diagnosis was highly sensitive (84%) and specific (87%) for the detection of SCLC. Screening for SOX2 and neuronal antibodies is a useful adjunct to clinical predictive scoring tools in predicting SCLC in LEMS.
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Affiliation(s)
- Paul Maddison
- Department of Neurology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham NG7 2UH, UK.
| | - Paul Gozzard
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
| | - Girija Sadalage
- Division of Neurology, University of Nottingham, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
| | - Philip A Ambrose
- Division of Neurology, University of Nottingham, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
| | - Caroline J Chapman
- Department of Pathology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | | | - Selina Thomsen
- Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Oxford OX3 9DS, UK
| | - Antonio Berretta
- Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Oxford OX3 9DS, UK
| | - Bethan Lang
- Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Oxford OX3 9DS, UK
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Broser PJ, Lütschg J. Die Bedeutung neurophysiologischer Methoden in der Abklärung neuropädiatrischer und neuromuskulärer Erkrankungen. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-00819-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Beecher G, Putko BN, Wagner AN, Siddiqi ZA. Therapies Directed Against B-Cells and Downstream Effectors in Generalized Autoimmune Myasthenia Gravis: Current Status. Drugs 2019; 79:353-364. [PMID: 30762205 DOI: 10.1007/s40265-019-1065-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Myasthenia gravis is a rare, heterogeneous, classical autoimmune disease characterized by fatigable skeletal muscle weakness, which is directly mediated by autoantibodies targeting various components of the neuromuscular junction, including the acetylcholine receptor, muscle specific tyrosine kinase, and lipoprotein-related protein 4. Subgrouping of myasthenia gravis is dependent on the age of onset, pattern of clinical weakness, autoantibody detected, type of thymic pathology, and response to immunotherapy. Generalized immunosuppressive therapies are effective in all subgroups of myasthenia gravis; however, approximately 15% remain refractory and more effective treatments with improved safety profiles are needed. In recent years, successful utilization of targeted B-cell therapies in this disease has triggered renewed focus in unraveling the underlying immunopathology in attempts to identify newer therapeutic targets. While myasthenia gravis is predominantly B-cell mediated, T cells, T cell-B cell interactions, and B-cell-related factors are increasingly recognized to play key roles in its immunopathology, particularly in autoantibody production, and novel therapies have focused on targeting these specific immune system components. This overview describes the current understanding of myasthenia gravis immunopathology before discussing B-cell-related therapies, their therapeutic targets, and the rationale and evidence for their use. Several prospective studies demonstrated efficacy of rituximab in various myasthenia gravis subtypes, particularly that characterized by antibodies against muscle-specific tyrosine kinase. However, a recent randomized control trial in patients with acetylcholine receptor antibodies was negative. Eculizumab, a complement inhibitor, has recently gained regulatory approval for myasthenia gravis based on a phase III trial that narrowly missed its primary endpoint while achieving robust results in all secondary endpoints. Zilucoplan is a subcutaneously administered terminal complement inhibitor that recently demonstrated significant improvements in functional outcome measures in a phase II trial. Rozanolixizumab, CFZ533, belimumab, and bortezomib are B-cell-related therapies that are in the early stages of evaluation in treating myasthenia gravis. The rarity of myasthenia gravis, heterogeneity in its clinical manifestations, and variability in immunosuppressive regimens are challenges to conducting successful trials. Nonetheless, these are promising times for myasthenia gravis, as renewed research efforts provide novel insights into its immunopathology, allowing for development of targeted therapies with increased efficacy and safety.
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Affiliation(s)
- Grayson Beecher
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada
| | - Brendan Nicholas Putko
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada
| | - Amanda Nicole Wagner
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada
| | - Zaeem Azfer Siddiqi
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, 7-112 Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada.
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20
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Raja SM, Sanders DB, Juel VC, Harati Y, Smith AG, Pascuzzi R, Richman DP, Wu A, Aleš KL, Jacobus LR, Jacobus DP, Guptill JT. Validation of the triple timed up-and-go test in Lambert-Eaton myasthenia. Muscle Nerve 2019; 60:292-298. [PMID: 31269226 DOI: 10.1002/mus.26625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 06/27/2019] [Accepted: 06/29/2019] [Indexed: 12/22/2022]
Abstract
INTRODUCTION There are no validated, practical, and quantitative measures of disease severity in Lambert-Eaton myasthenia (LEM). METHODS Data from the Effectiveness of 3,4-Diaminopyridine in Lambert-Eaton Myasthenic Syndrome (DAPPER) trial were analyzed to assess triple timed up-and-go (3TUG) reproducibility and relationships between 3TUG times and other measures of LEM severity. RESULTS The coverage probability technique showed ≥0.90 probability for an acceptable 3TUG difference of ≤0.2, indicating that it is reproducible in LEM patients. The correlation between 3TUG times and lower extremity function scores was significant in subjects who continued and in those who were withdrawn from 3,4-diaminopyridine free base. Worsening patient-reported Weakness Self-Assessment Scale and Investigator Assessment of Treatment Effect scores corresponded with prolongation of 3TUG times. DISCUSSION The 3TUG is reproducible, demonstrates construct validity for assessment of lower extremity function in LEM patients, and correlates with changes in patient and physician assessments. These findings, along with prior reliability studies, indicate 3TUG is a valid measure of disease severity in LEM.
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Affiliation(s)
- Shruti M Raja
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Vern C Juel
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Yadollah Harati
- Department of Neurology, Baylor College of Medicine, Houston, Texas
| | - A Gordon Smith
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Robert Pascuzzi
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - David P Richman
- Department of Neurology, University of California Davis Medical Center, Sacramento, California
| | - Angie Wu
- Center for Predictive Modeling, Duke Clinical Research Institute, Durham, North Carolina
| | - Kathy L Aleš
- Jacobus Pharmaceutical Company, Princeton, New Jersey
| | | | | | - Jeffrey T Guptill
- Department of Neurology, Duke University Medical Center, Durham, North Carolina.,Neurosciences Medicine, Duke Clinical Research Institute, Durham, North Carolina
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Ivanovski T, Miralles F. Lambert-Eaton Myasthenic syndrome: early diagnosis is key. Degener Neurol Neuromuscul Dis 2019; 9:27-37. [PMID: 31191084 PMCID: PMC6524763 DOI: 10.2147/dnnd.s192588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/18/2019] [Indexed: 12/12/2022] Open
Abstract
Lambert-Eaton myasthenic syndrome (LEMS) is an uncommon disorder of neuromuscular transmission with distinctive pathophysiological, clinical, electrophysiological and laboratory features. There are two forms of LEMS. The paraneoplastic (P-LEMS) form is associated with a malignant tumor that is most frequently a small cell lung carcinoma (SCLC), and the autoimmune (A-LEMS) form is often related to other dysimmune diseases. Approximately 90% of LEMS patients present antibodies against presynaptic membrane P/Q-type voltage-gated calcium channels (VGCC). These antibodies are directly implicated in the pathophysiology of the disorder, provoke reduced acetylcholine (ACh) at the nerve terminal and consequently lead to muscle weakness. LEMS is clinically characterized by proximal muscle weakness, autonomic dysfunction and areflexia. In clinically suspected cases, diagnoses are confirmed by serological and electrodiagnostic tests. The detection of P/Q-type VGCC antibodies is supportive when there is clinical suspicion but should be carefully interpreted in the absence of characteristic clinical or electrodiagnostic features. Typical electrodiagnostic findings (ie, reduced compound motor action potentials (CMAPs), significant decrements in the responses to low frequency stimulation and incremental responses after brief exercise or high-frequency stimulation) reflect the existence of a presynaptic transmission defect and are key confirmatory criteria. Diagnosis requires a high level of awareness and necessitates the initiation of a prompt screening and surveillance process to detect and treat malignant tumors. In clinically affected patients without cancer and after cancer treatment, symptomatic treatment with 3,4-diaminopyridine or immunosuppressive agents can significantly improve neurologic symptoms and the quality of life. We present a detailed review of LEMS with special emphasis on the pathophysiological mechanisms, clinical manifestation and diagnostic procedure.
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Affiliation(s)
- Trajche Ivanovski
- Neurology Department, Hospital Universitari Son Llatzer, Palma de Mallorca, Balearic Islands, Spain
| | - Francesc Miralles
- Neurology Department, Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain
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22
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Li F, Ismail M, Elsner A, Uluk D, Bauer G, Meisel A, Rueckert JC. Surgical Techniques for Myasthenia Gravis. Thorac Surg Clin 2019; 29:177-186. [DOI: 10.1016/j.thorsurg.2018.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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23
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Tsironis T, Catania S. Reversible spontaneous EMG activity during myasthenic crisis: Two case reports. eNeurologicalSci 2018; 14:16-18. [PMID: 30555945 PMCID: PMC6275166 DOI: 10.1016/j.ensci.2018.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 11/17/2018] [Indexed: 11/15/2022] Open
Abstract
Background Myasthenia Gravis (MG) is an antibody-mediated autoimmune neuromuscular disorder, clinically presenting with fatigable variable muscle weakness. Typical electrodiagnostic findings are a decremental response to repetitive nerve stimulation with post-exercise facilitation, and motor unit instability expressed as increased jitter on single fibre-EMG. Presence of spontaneous activity on standard EMG is traditionally considered inconsistent with a diagnosis of MG and would direct the differential diagnosis towards a primary denervating or usually inflammatory myopathic process.Case reportWe herein present two patients with progressive severe bulbar symptomatology, whose needle-EMG examinations showed spontaneous activity and led to erroneous initial diagnoses of inflammatory myopathy and anterior horn cell disease respectively. Follow-up neurophysiological investigations, positive anti-AchR titres and good response to IVIg and steroids eventually established the diagnosis of Myasthenia Gravis. Conclusions Clinically severe Myasthenia Gravis can potentially present with spontaneous activity on EMG, mimicking acute myopathic or neurogenic processes. This can prove particularly perplexing and cause significant delays in the diagnosis and treatment of a myasthenia relapse.
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Affiliation(s)
- Theocharis Tsironis
- Department of Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.,Department of Neurology, Department of Clinical Neurophysiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Santiago Catania
- Department of Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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24
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Leonardi L, Haggiag S, Petrucci A, Lispi L. Electrophysiological abnormalities in iatrogenic botulism: Two case reports and review of the literature. J Clin Neurosci 2018; 60:138-141. [PMID: 30348587 DOI: 10.1016/j.jocn.2018.10.059] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/06/2018] [Indexed: 11/28/2022]
Abstract
Therapeutic use of botulinum neurotoxin type A (BoNT/A) is effective, and generally safe. Nevertheless, iatrogenic botulism (IB) is rarely reported as a result of systemic spread of the BoNT/A, causing general weakness, bulbar symptoms and dysautonomia. Suggestive clinical feature are decisive to raise the diagnostic suspicion, which however needs a confirmation in the electrodiagnostic (EDX) study, above all to exclude other treatable diseases. In this study, we report 2 patients who developed IB after receiving therapeutic doses of BoNT/A, assessing the EDX changes, and reviewing the literature on EDX in IB. Although there is not enough data to draw solid conclusions we propose that, in a subject with suggestive clinical features and recent exposure to BoNT/A, the absence of a decremental or incremental response to repetitive nerve stimulation in muscles showing acute denervation changes, is a suggestive finding for the diagnosis of IB.
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Affiliation(s)
- Luca Leonardi
- Neurosciences Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039, 00189 Roma, Rome, Italy.
| | - Shalom Haggiag
- Neuroscience Department, San Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Antonio Petrucci
- Neuroscience Department, San Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Ludovico Lispi
- Neuroscience Department, San Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy
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Zouari R, Hdiji O, Kacem HH, Bouattour N, Farhat N, Sakka S, Dammak M, Mhiri C. Repetitive nerve stimulation: Relative muscles sensitivity in generalized myasthenia gravis. Neurophysiol Clin 2018. [DOI: 10.1016/j.neucli.2018.06.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Ateş F, Davies BL, Chopra S, Coleman-Wood K, Litchy WJ, Kaufman KR. Intramuscular Pressure of Tibialis Anterior Reflects Ankle Torque but Does Not Follow Joint Angle-Torque Relationship. Front Physiol 2018; 9:22. [PMID: 29416514 PMCID: PMC5787576 DOI: 10.3389/fphys.2018.00022] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/09/2018] [Indexed: 11/21/2022] Open
Abstract
Intramuscular pressure (IMP) is the hydrostatic fluid pressure that is directly related to muscle force production. Electromechanical delay (EMD) provides a link between mechanical and electrophysiological quantities and IMP has potential to detect local electromechanical changes. The goal of this study was to assess the relationship of IMP with the mechanical and electrical characteristics of the tibialis anterior muscle (TA) activity at different ankle positions. We hypothesized that (1) the TA IMP and the surface EMG (sEMG) and fine-wire EMG (fwEMG) correlate to ankle joint torque, (2) the isometric force of TA increases at increased muscle lengths, which were imposed by a change in ankle angle and IMP follows the length-tension relationship characteristics, and (3) the electromechanical delay (EMD) is greater than the EMD of IMP during isometric contractions. Fourteen healthy adults [7 female; mean (SD) age = 26.9 (4.2) years old with 25.9 (5.5) kg/m2 body mass index] performed (i) three isometric dorsiflexion (DF) maximum voluntary contraction (MVC) and (ii) three isometric DF ramp contractions from 0 to 80% MVC at rate of 15% MVC/second at DF, Neutral, and plantarflexion (PF) positions. Ankle torque, IMP, TA fwEMG, and TA sEMG were measured simultaneously. The IMP, fwEMG, and sEMG were significantly correlated to the ankle torque during ramp contractions at each ankle position tested. This suggests that IMP captures in vivo mechanical properties of active muscles. The ankle torque changed significantly at different ankle positions however, the IMP did not reflect the change. This is explained with the opposing effects of higher compartmental pressure at DF in contrast to the increased force at PF position. Additionally, the onset of IMP activity is found to be significantly earlier than the onset of force which indicates that IMP can be designed to detect muscular changes in the course of neuromuscular diseases impairing electromechanical transmission.
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Affiliation(s)
- Filiz Ateş
- Motion Analysis Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Brenda L Davies
- Motion Analysis Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Swati Chopra
- Motion Analysis Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Krista Coleman-Wood
- Motion Analysis Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - William J Litchy
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Kenton R Kaufman
- Motion Analysis Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
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Saidi T, Sivarasu S, Douglas TS. Open source modular ptosis crutch for the treatment of myasthenia gravis. Expert Rev Med Devices 2018; 15:137-143. [PMID: 29271663 DOI: 10.1080/17434440.2018.1421455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Pharmacologic treatment of Myasthenia Gravis presents challenges due to poor tolerability in some patients. Conventional ptosis crutches have limitations such as interference with blinking which causes ocular surface drying, and frequent irritation of the eyes. To address this problem, a modular and adjustable ptosis crutch for elevating the upper eyelid in Myasthenia Gravis patients has been proposed as a non-surgical and low-cost solution. AREAS COVERED This paper reviews the literature on the challenges in the treatment of Myasthenia Gravis globally and focuses on a modular and adjustable ptosis crutch that has been developed by the Medical Device Laboratory at the University of Cape Town. EXPERT COMMENTARY The new medical device has potential as a simple, effective and unobtrusive solution to elevate the drooping upper eyelid(s) above the visual axis without the need for medication and surgery. Access to the technology is provided through an open source platform which makes it available globally. Open access provides opportunities for further open innovation to address the current limitations of the device, ultimately for the benefit not only of people suffering from Myasthenia Gravis but also of those with ptosis from other aetiologies.
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Affiliation(s)
- Trust Saidi
- a Department of Human Biology , Division of Biomedical Engineering, University of Cape Town , Cape Town , South Africa
| | - Sudesh Sivarasu
- a Department of Human Biology , Division of Biomedical Engineering, University of Cape Town , Cape Town , South Africa
| | - Tania S Douglas
- a Department of Human Biology , Division of Biomedical Engineering, University of Cape Town , Cape Town , South Africa
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28
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Maddison P, Gozzard P, Grainge MJ, Lang B. Long-term survival in paraneoplastic Lambert-Eaton myasthenic syndrome. Neurology 2017; 88:1334-1339. [DOI: 10.1212/wnl.0000000000003794] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 01/17/2017] [Indexed: 01/19/2023] Open
Abstract
Objective:To establish whether improved tumor survival in patients with Lambert-Eaton myasthenic syndrome (LEMS) and small-cell lung cancer (SCLC) was due to known prognostic risk factors or an effect of LEMS independently, perhaps as a result of circulating factors.Methods:We undertook a prospective observational cohort study of patients with LEMS attending Nottingham University Hospitals, UK, or via the British Neurological Surveillance Unit. In parallel, patients with a new diagnosis of biopsy-proven SCLC were enrolled, examined for neurologic illness, and followed up until death or study end.Results:Between May 2005 and November 2014, we recruited 31 patients with LEMS and SCLC and 279 patients with SCLC without neurologic illness. Allowing for known SCLC survival prognostic factors of disease extent, age, sex, performance status, and sodium values, multivariate Cox regression analysis showed that the presence of LEMS with SCLC conferred a significant survival advantage independently of the other prognostic variables (hazard ratio 1.756, 95% confidence interval 1.137–2.709, p = 0.011).Conclusions:Improved SCLC tumor survival seen in patients with LEMS and SCLC may not be due solely to lead time bias, given that survival advantage remains after allowing for other prognostic factors and that the same degree of survival advantage is not seen in patients with paraneoplastic neurologic syndromes other than LEMS presenting before SCLC diagnosis.
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29
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Bou Ali H, Salort-Campana E, Grapperon AM, Gallard J, Franques J, Sevy A, Delmont E, Verschueren A, Pouget J, Attarian S. New strategy for improving the diagnostic sensitivity of repetitive nerve stimulation in myasthenia gravis. Muscle Nerve 2017; 55:532-538. [DOI: 10.1002/mus.25374] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Hanna Bou Ali
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- INSERM U910 Aix-Marseille University; Marseille France
| | - Emmanuelle Salort-Campana
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- INSERM U910 Aix-Marseille University; Marseille France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
| | - Aude Marie Grapperon
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- INSERM U910 Aix-Marseille University; Marseille France
| | - Julien Gallard
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
| | - Jerome Franques
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
| | - Amandine Sevy
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
| | - Emilien Delmont
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
| | - Annie Verschueren
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
| | - Jean Pouget
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- INSERM U910 Aix-Marseille University; Marseille France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
| | - Shahram Attarian
- Reference Center for Neuromuscular Disorders and ALS; Timone University Hospital; 264 rue Saint-Pierre, Marseille Cedex 05 13385 France
- INSERM U910 Aix-Marseille University; Marseille France
- FILNEMUS, Filière nationale des maladies neuromusculaires; Marseille France
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Affiliation(s)
- Nils E Gilhus
- From the Department of Clinical Medicine, University of Bergen, and the Department of Neurology, Haukeland University Hospital - both in Bergen, Norway
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31
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Grisold W, Grisold A, Löscher WN. Neuromuscular complications in cancer. J Neurol Sci 2016; 367:184-202. [PMID: 27423586 DOI: 10.1016/j.jns.2016.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 05/08/2016] [Accepted: 06/01/2016] [Indexed: 12/11/2022]
Abstract
Cancer is becoming a treatable and even often curable disease. The neuromuscular system can be affected by direct tumor invasion or metastasis, neuroendocrine, metabolic, dysimmune/inflammatory, infections and toxic as well as paraneoplastic conditions. Due to the nature of cancer treatment, which frequently is based on a DNA damaging mechanism, treatment related toxic side effects are frequent and the correct identification of the causative mechanism is necessary to initiate the proper treatment. The peripheral nervous system is conventionally divided into nerve roots, the proximal nerves and plexus, the peripheral nerves (mono- and polyneuropathies), the site of neuromuscular transmission and muscle. This review is based on the anatomic distribution of the peripheral nervous system, divided into cranial nerves (CN), motor neuron (MND), nerve roots, plexus, peripheral nerve, the neuromuscular junction and muscle. The various etiologies of neuromuscular complications - neoplastic, surgical and mechanic, toxic, metabolic, endocrine, and paraneoplastic/immune - are discussed separately for each part of the peripheral nervous system.
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Affiliation(s)
- W Grisold
- Department of Neurology, Kaiser Franz Josef Hospital, Vienna, Austria.
| | - A Grisold
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - W N Löscher
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Patel A, Gosk M, Pitt M. The effect of different low-frequency filters on concentric needle jitter in stimulated orbicularis oculi. Muscle Nerve 2016; 54:317-9. [DOI: 10.1002/mus.25178] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Anjla Patel
- Department of Clinical Neurophysiology; Great Ormond Street Hospital For Children NHS Foundation Trust; Great Ormond Street London WC1N 3JH UK
- Department of Clinical Neurophysiology; Luton and Dunstable Hospital NHS Foundation Trust; Lewsey Road Luton LU4 0DZ UK
| | - Magdalena Gosk
- Department of Clinical Neurophysiology; Great Ormond Street Hospital For Children NHS Foundation Trust; Great Ormond Street London WC1N 3JH UK
- Department of Paediatrics; Gottfried von Preyer'sches Kinderspital; Vienna Austria
| | - Matthew Pitt
- Department of Clinical Neurophysiology; Great Ormond Street Hospital For Children NHS Foundation Trust; Great Ormond Street London WC1N 3JH UK
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33
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Myasthenia gravis — autoantibody characteristics and their implications for therapy. Nat Rev Neurol 2016; 12:259-68. [DOI: 10.1038/nrneurol.2016.44] [Citation(s) in RCA: 209] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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34
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Gilhus NE, Kerty E, Løseth S, Mygland Å, Tallaksen C. Myasthenia gravis – diagnostikk og behandling. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1089-94. [DOI: 10.4045/tidsskr.15.1259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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