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Fenioux C, Abbar B, Boussouar S, Bretagne M, Power JR, Moslehi JJ, Gougis P, Amelin D, Dechartres A, Lehmann LH, Courand PY, Cautela J, Alexandre J, Procureur A, Rozes A, Leonard-Louis S, Qin J, Cheynier R, Charmeteau-De Muylder B, Redheuil A, Tubach F, Cadranel J, Milon A, Ederhy S, Similowski T, Johnson DB, Pizzo I, Catalan T, Benveniste O, Hayek SS, Allenbach Y, Rosenzwajg M, Dolladille C, Salem JE. Thymus alterations and susceptibility to immune checkpoint inhibitor myocarditis. Nat Med 2023; 29:3100-3110. [PMID: 37884625 DOI: 10.1038/s41591-023-02591-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 09/15/2023] [Indexed: 10/28/2023]
Abstract
Immune checkpoint inhibitors (ICI) have transformed the therapeutic landscape in oncology. However, ICI can induce uncommon life-threatening autoimmune T-cell-mediated myotoxicities, including myocarditis and myositis. The thymus plays a critical role in T cell maturation. Here we demonstrate that thymic alterations are associated with increased incidence and severity of ICI myotoxicities. First, using the international pharmacovigilance database VigiBase, the Assistance Publique Hôpitaux de Paris-Sorbonne University data warehouse (Paris, France) and a meta-analysis of clinical trials, we show that ICI treatment of thymic epithelial tumors (TET, and particularly thymoma) was more frequently associated with ICI myotoxicities than other ICI-treated cancers. Second, in an international ICI myocarditis registry, we established that myocarditis occurred earlier after ICI initiation in patients with TET (including active or prior history of TET) compared to other cancers and was more severe in terms of life-threatening arrythmias and concurrent myositis, leading to respiratory muscle failure and death. Lastly, we show that presence of anti-acetylcholine-receptor antibodies (a biological proxy of thymic-associated autoimmunity) was more prevalent in patients with ICI myocarditis than in ICI-treated control patients. Altogether, our results highlight that thymic alterations are associated with incidence and seriousness of ICI myotoxicities. Clinico-radio-biological workup evaluating the thymus may help in predicting ICI myotoxicities.
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Affiliation(s)
- Charlotte Fenioux
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
- Hôpitaux de Paris, Henri Mondor Hospital, Department of Oncology, Créteil, France
| | - Baptiste Abbar
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
- Hôpitaux de Paris, Pitié Salpêtrière Hospital, Department of Oncology, Paris, France
| | - Samia Boussouar
- Hôpitaux de Paris, Pitié Salpêtrière Hospital, Department of Radiology, Paris, France
| | - Marie Bretagne
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
| | - John R Power
- Department of Medecine, University of California, San Diego, San Diego, CA, USA
| | - Javid J Moslehi
- Department of Medecine, University of California, San Francisco, San Francisco, CA, USA
| | - Paul Gougis
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
| | - Damien Amelin
- Sorbonne Université, INSERM, Association Institut de Myologie, Center of Research in Myology, UMRS 974, Paris, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité de Recherche Clinique PSL-CFX, CIC-1901, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Lorenz H Lehmann
- Department of Cardiology, University Hospital Heidelberg; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Pierre-Yves Courand
- Fédération de Cardiologie, IMMUCARE, Hôpital de La Croix-Rousse Et Hôpital Lyon Sud, Hospices Civils de Lyon; Université de Lyon, CREATIS UMR INSERM U1044, INSA, Lyon, France
| | - Jennifer Cautela
- Aix-Marseille University, University Mediterranean Center of Cardio-Oncology, Unit of Heart Failure and Valvular Heart Diseases, Center for Cardiovascular and Nutrition Research, INSERM 1263, INRAE 1260, Nord Hospital, Assistance Publique-Hôpitaux de Marseille, Paris, France
| | - Joachim Alexandre
- CHU de Caen Normandie, Department of Pharmacology, Pharmacoepidemiology Unit; Normandie Université, UNICAEN, INSERM U1086 ANTICIPE Centre François Baclesse, Caen, France
| | - Adrien Procureur
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
| | - Antoine Rozes
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité de Recherche Clinique PSL-CFX, CIC-1901, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Sarah Leonard-Louis
- Hôpitaux de Paris, Pitié Salpêtrière Hospital, Laboratoire de Neuropathologie, Paris, France
| | - Juan Qin
- Department of Medecine, University of California, San Francisco, San Francisco, CA, USA
| | - Rémi Cheynier
- Université Paris Cité, CNRS, INSERM, Institut Cochin, Paris, France
| | | | - Alban Redheuil
- Hôpitaux de Paris, Pitié Salpêtrière Hospital, Department of Radiology, Paris, France
| | - Florence Tubach
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Unité de Recherche Clinique PSL-CFX, CIC-1901, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Jacques Cadranel
- Hôpitaux de Paris, Tenon Hospital, Department of Pulmonology and Thoracic Oncology and GRC Theranoscan Sorbonne University, Paris, France
| | - Audrey Milon
- Hôpitaux de Paris, Tenon Hospital, Department of Radiology, Paris, France
| | - Stéphane Ederhy
- Hôpitaux de Paris, Saint-Antoine Hospital, Department of Cardiology, Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS 1158 Neurophysiologie respiratoire expérimentale et clinique'; Assistance Publique -Hôpitaux de Paris, Pitié-Salpêtrière Hospital, 'Département R3S', Paris, France
| | - Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ian Pizzo
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Toniemarie Catalan
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Olivier Benveniste
- Department of Internal Medicine, Sorbonne University, AP-HP, INSERM UMRS 974, Pitié-Salpêtrière Hospital, Paris, France
| | - Salim S Hayek
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Yves Allenbach
- Department of Internal Medicine, Sorbonne University, AP-HP, INSERM UMRS 974, Pitié-Salpêtrière Hospital, Paris, France
| | - Michelle Rosenzwajg
- Hôpitaux de Paris, Pitié Salpêtrière Hospital, Department of Immunology, Paris, France
| | - Charles Dolladille
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France
| | - Joe-Elie Salem
- Sorbonne Université, INSERM, CIC-1901 Paris-Est, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, Paris, France.
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Bireley JD, Santucci J, Li Y, Cohen DA. Clinical Reasoning: An Unusual Cause of Diplopia and Ptosis in a 67-Year-Old Woman. Neurology 2023; 101:e1646-e1651. [PMID: 37527939 PMCID: PMC10585670 DOI: 10.1212/wnl.0000000000207676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/06/2023] [Indexed: 08/03/2023] Open
Abstract
Diplopia is a relatively common chief complaint encountered in an outpatient neurology clinic and carries a broad differential diagnosis. In this case, a 67-year-old woman presented with new horizontal, binocular diplopia and ptosis of 8-month duration, which persisted without significant progression. This case highlights the need for a comprehensive list of differential diagnoses for patients with acquired ophthalmoplegia and ptosis. Key learning points include an illustration of the stepwise diagnostic approach to evaluate for common etiologies, the importance of interpreting test results in the appropriate clinical setting, and the significance of recognizing specific signs and symptoms in achieving the correct diagnosis.
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Affiliation(s)
- John Daniel Bireley
- From the Department of Neurology (J.D.B., J.S., Y.L.), Neurological Institute, and Department of Ophthalmology (D.A.C.), Cole Eye Institute, Cleveland Clinic, OH
| | - Joshua Santucci
- From the Department of Neurology (J.D.B., J.S., Y.L.), Neurological Institute, and Department of Ophthalmology (D.A.C.), Cole Eye Institute, Cleveland Clinic, OH
| | - Yuebing Li
- From the Department of Neurology (J.D.B., J.S., Y.L.), Neurological Institute, and Department of Ophthalmology (D.A.C.), Cole Eye Institute, Cleveland Clinic, OH
| | - Devon A Cohen
- From the Department of Neurology (J.D.B., J.S., Y.L.), Neurological Institute, and Department of Ophthalmology (D.A.C.), Cole Eye Institute, Cleveland Clinic, OH.
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Li Z, Zhang C, Chang T, Zhang X, Yang H, Gao F, Feng J, Liu H, Chen S, Wang L, Yang C, Li H, Pan Y, Palace J, Shi FD. A multicentre, prospective, double-blind study comparing the accuracy of autoantibody diagnostic assays in myasthenia gravis: the SCREAM study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 38:100846. [PMID: 37554174 PMCID: PMC10404541 DOI: 10.1016/j.lanwpc.2023.100846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Laboratory determination of autoantibodies against acetylcholine receptor (AChR), muscle-specific kinase (MuSK) and other autoantigens have been integrated into the diagnosis of myasthenia gravis (MG). However, evidence supporting the selection of methodologies is lacking. METHODS In this prospective, multicentre cohort study, we recruited patients with suspected MG to evaluate the diagnostic accuracy of cell-based assay (CBA), radioimmunoprecipitation assay (RIPA) and enzyme-linked immunosorbent assay (ELISA) in detecting AChR and MuSK autoantibodies. This study is registered with www.clinicaltrials.gov, number NCT05219097. FINDINGS 2272 eligible participants were recruited, including 2043 MG, 229 non-MG subjects. AChR antibodies were detected in 1478, 1310, and 1280 out of a total of 2043 MG patients by CBA, RIPA, and ELISA, respectively; sensitivity, 72.3% (95% CI, 70.3-74.3), 64.1% (95% CI, 62.0-66.2), 62.7% (95% CI, 60.5-64.8); specificity, 97.8% (95% CI, 95.0-99.3), 97.8% (95% CI, 95.0-99.3), 94.8% (95% CI, 91.9-97.7). MuSK antibodies were found in 59, 50, and 54 from 2043 MG patients by CBA, RIPA and ELISA, respectively; sensitivity, 2.9% (95% CI, 2.2-3.7), 2.4% (95% CI, 1.8-3.2), 2.6% (95% CI, 2.0-3.4); specificity, 100% (95% CI, 98.4-100), 100% (95% CI, 98.4-100), and 99.1% (95% CI, 96.9-99.9). The area under the curve of AChR antibodies tested by CBA was 0.858, and there were statistical differences with RIPA (0.843; p = 0.03) and ELISA (0.809; p < 0.0001). INTERPRETATION CBA has a higher diagnostic accuracy compared to RIPA or ELISA in detecting AChR and MuSK autoantibodies for MG diagnosis. FUNDING New Terrain Biotechnology, Inc., Tianjin, China.
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Affiliation(s)
- Zhiguo Li
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Chao Zhang
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an, Shanxi, China
| | - Xinghu Zhang
- Centre for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Academy of Medical Science, Zhengzhou University, Zhengzhou, China
| | - Jinzhou Feng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hongbo Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Sheng Chen
- Department of Neurology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chunsheng Yang
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Huining Li
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuesong Pan
- Centre for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jacqueline Palace
- Department of Neurology, John Radcliffe Hospital Oxford, Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Fu-Dong Shi
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
- Centre for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Andrapalliyal N, Claytor B, Li Y. Incidence and causes of overdiagnosis of myasthenia gravis. Muscle Nerve 2022; 67:464-468. [PMID: 36533968 DOI: 10.1002/mus.27774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 12/06/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION/AIMS We have encountered non-myasthenic patients being given a diagnosis of myasthenia gravis (MG). This study aims to investigate the frequency of, and factors contributing to, overdiagnosis of MG. METHODS This is a retrospective analysis of patients referred to our tertiary neuromuscular center for evaluation due to a previously suspected/confirmed MG diagnosis during a 6-year span. RESULTS A total of 531 patients sought a second opinion regarding their MG diagnosis, and 77 (14.5%) were found to have non-myasthenic conditions. A total of 11 patients tested positive for acetylcholine receptor (AChR) antibodies. Repeated AChR antibodies became negative in five patients while in four patients, AChR binding antibody titers were persistently low. In seven patients, striational antibody was the only positive antibody identified. In 25 patients, a prior electrodiagnostic (EDX) study was deemed positive, including 14 patients with abnormal repetitive nerve stimulation (RNS) and 12 with abnormal single fiber electromyography (SFEMG). Technical issues were noted on prior RNS studies in 8 patients, and repeat RNS was negative in 10 patients. In eight patients with previously abnormal SFEMG, results showed minimal or equivocal abnormalities. In two patients, a repeat SFEMG was normal. Further analysis revealed atypical clinical presentation, deceptively positive ice pack test, clinically insignificant antibody result and misleading EDX finding as main contributors to MG overdiagnosis. DISCUSSION Overdiagnosis of MG is not uncommon, and occurs more frequently in seronegative patients. To make an accurate diagnosis of MG, there is a need to recognize atypical presentations, and avoid overreliance on minor or non-specific serological and electrodiagnostic findings.
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Affiliation(s)
- Nirmal Andrapalliyal
- Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Benjamin Claytor
- Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Yuebing Li
- Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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