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Krenn M, Grisold A, Wohlfarth P, Rath J, Cetin H, Koneczny I, Zimprich F. Pathomechanisms and Clinical Implications of Myasthenic Syndromes Exacerbated and Induced by Medical Treatments. Front Mol Neurosci 2020; 13:156. [PMID: 32922263 PMCID: PMC7457047 DOI: 10.3389/fnmol.2020.00156] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/28/2020] [Indexed: 12/21/2022] Open
Abstract
Myasthenic syndromes are typically characterized by muscle weakness and increased fatigability due to an impaired transmission at the neuromuscular junction (NMJ). Most cases are caused by acquired autoimmune conditions such as myasthenia gravis (MG), typically with antibodies against the acetylcholine receptor (AChR). Different drugs are among the major factors that may complicate pre-existing autoimmune myasthenic conditions by further impairing transmission at the NMJ. Some clinical observations are substantiated by experimental data, indicating that presynaptic, postsynaptic or more complex pathomechanisms at the NMJ may be involved, depending on the individual compound. Most robust data exist for the risks associated with some antibiotics (e.g., aminoglycosides, ketolides, fluoroquinolones) and cardiovascular medications (e.g., class Ia antiarrhythmics, beta blockers). Apart from primarily autoimmune-mediated disorders of the NMJ, de novo myasthenic manifestations may also be triggered by medical treatments that induce an autoimmune reaction. Most notably, there is growing evidence that the immune checkpoint inhibitors (ICI), a modern class of drugs to treat various malignancies, represent a relevant risk factor to develop severe and progressive medication-induced myasthenia via an immune-mediated mechanism. From a clinical perspective, it is of utmost importance for the treating physicians to be aware of such adverse treatment effects and their consequences. In this article, we aim to summarize existing evidence regarding the key molecular and immunological mechanisms as well as the clinical implications of medication-aggravated and medication-induced myasthenic syndromes.
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Affiliation(s)
- Martin Krenn
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Anna Grisold
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Philipp Wohlfarth
- Division of Blood and Marrow Transplantation, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Jakob Rath
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Hakan Cetin
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Inga Koneczny
- Department of Neurology, Medical University of Vienna, Vienna, Austria.,Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Fritz Zimprich
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Howard JF, Sanders DB. Chapter 12 Neurotoxicology of neuromuscular transmission. HANDBOOK OF CLINICAL NEUROLOGY 2008; 91:369-400. [DOI: 10.1016/s0072-9752(07)01512-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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Zivković SA, Medsger TA. Myasthenia gravis and scleroderma: Two cases and a review of the literature. Clin Neurol Neurosurg 2007; 109:388-91. [PMID: 17280777 DOI: 10.1016/j.clineuro.2007.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Revised: 01/02/2007] [Accepted: 01/05/2007] [Indexed: 10/23/2022]
Abstract
Myasthenia gravis is uncommon in patients with scleroderma, and when diagnosed is usually associated with previous use of d-penicillamine. Clinically, both myasthenia and scleroderma may present with fatigue, weakness and bulbar symptoms, so one of diagnoses may be delayed. We report two new cases and review clinical features of 12 other reported cases of co-existing scleroderma and myasthenia gravis, unrelated to previous d-penicillamine therapy. Co-occurrence of myasthenia and scleroderma was reported almost exclusively (13/14) in women with a mean latency of 7.03 years. Most patients (10/11) had seropositive generalized myasthenia, and there were no cases with exclusively ocular symptoms. Three patients with pre-existing myasthenia were safely treated with d-penicillamine. Myasthenia and scleroderma occur in the context of an underlying autoimmune diathesis, but their co-occurrence could be underreported as the recognition of either disorder may be delayed by overlapping clinical symptoms. Our findings also suggest that d-penicillamine may be cautiously used in selected patients with pre-existing scleroderma and myasthenia, when potential benefits outweigh the risk of possible myasthenia exacerbation.
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Affiliation(s)
- Sasa A Zivković
- VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, United States.
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Kaneko S, Ito H, Kusaka H, Imai T, Nishimura T, Yoshikawa H. Peripheral myelin protein-22 gene deletion in two unrelated Japanese pedigrees with hereditary neuropathy with liability to pressure palsies. Muscle Nerve 1996; 19:675-6. [PMID: 8618572 DOI: 10.1002/mus.880190502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Topaktas S, Dalkara T, Onur R, Ruacan S. Intrathymic injection of D-penicillamine does not induce myasthenia-like disorder in the mouse and rat. Muscle Nerve 1992; 15:1299-300. [PMID: 1488069 DOI: 10.1002/mus.880151113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Rooney PJ, Bálint GP, Szebenyi B, Petrou P. Rheumatic syndromes caused by antirheumatic drugs. BAILLIERE'S CLINICAL RHEUMATOLOGY 1991; 5:139-73. [PMID: 1676937 DOI: 10.1016/s0950-3579(05)80300-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Yamamoto M, Akiyama C, Aikawa H. D-penicillamine-induced copper deficiency in suckling mice: neurological abnormalities and brain mitochondrial enzyme activities. BRAIN RESEARCH. DEVELOPMENTAL BRAIN RESEARCH 1990; 55:51-5. [PMID: 2170057 DOI: 10.1016/0165-3806(90)90105-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Brain mitochondrial enzyme activities were examined in 15-day-old suckling mice which were daily injected with D-penicillamine (DP), a chelating agent of copper. Newborn mice treated with DP (1 g/kg/day) showed retarded weight gain, hyperelasticity of skin, and a bizarre forelimb posture with subcutaneous edema on experimental day (ED) 7. Paraparesis or dragging of the hindlimbs was observed by ED 15. Brain copper contents of DP-treated mice decreased to 34% of the controls of ED 15. Cytochrome c oxidase activity (complex IV) in the brain showed 51% decrease of the controls, on the contrary, rotenone-sensitive NADH cytochrome c reductase (complex I + III) and succinate cytochrome c reductase (complex II + III) were normal. Histochemistry of cytochrome c oxidase in the cerebellum of DP-treated mice disclosed diffuse reduction of staining, especially in Purkinje cells. These data show that DP-induced copper deficiency in the brain subsequently disturbs mitochondrial electron transport system, selectively cytochrome c oxidase activity. This seems to be a useful animal model not only for Menkes' kinky hair disease but also for mitochondrial encephalomyopathy.
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Affiliation(s)
- M Yamamoto
- Division of Ultrastructural Research, National Institute of Neuroscience, Tokyo, Japan
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Katz LJ, Lesser RL, Merikangas JR, Silverman JP. Ocular myasthenia gravis after D-penicillamine administration. Br J Ophthalmol 1989; 73:1015-8. [PMID: 2692700 PMCID: PMC1041959 DOI: 10.1136/bjo.73.12.1015] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A 68-year-old black woman who was put on D-penicillamine therapy (250-500 mg per day, total dose 15 g) for rheumatoid arthritis developed ocular myasthenia gravis. Two weeks after she discontinued D-penicillamine her signs and symptoms cleared with no other treatment. Review of previous cases and possible immunological mechanisms are discussed.
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Affiliation(s)
- L J Katz
- William and Anna Goldberg Glaucoma Service, Thomas Jefferson University, Philadelphia, PA 19107
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Abstract
Immunotoxicologic studies have demonstrated that autoimmune responses and/or autoimmune diseases are induced in humans and experimental animals by chronic exposure to various chemicals. The present review is focused on seven groups of chemically induced human disorders, i.e. systemic lupus erythematosus, autoimmune hemolytic anemia, myasthenia gravis, pemphigus, glomerulonephritis, thyroiditis and hepatitis. Results obtained from studies of the available experimental counterparts of these diseases, i.e. those models obtained from the exposure of laboratory animals to various chemicals, are then analyzed. Finally, we present the lessons that can be derived from immunotoxicologic investigations regarding mechanisms of induction, heterogeneity of chemicals involved, humoral vs. cellular immune responses and genetic predisposition to chemically induced autoimmunity.
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Affiliation(s)
- P E Bigazzi
- University of Connecticut Health Center, Farmington 06032
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Bever CT, Dretchen KL, Blake GJ, Chang HW, Penn AS, Asofsky R. Augmented anti-acetylcholine receptor response following long-term penicillamine administration. Ann Neurol 1984; 16:9-13. [PMID: 6431900 DOI: 10.1002/ana.410160103] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Because of the association of D-penicillamine (DP) therapy with myasthenia gravis, we have studied long-term DP treatment in five inbred strains of mice with doses comparable to those used in patients with rheumatoid arthritis. No clinical weakness or anti-acetylcholine receptor (AChR) antibody developed with up to 6 months of treatment, but augmented responses did occur to challenge with purified AChR in adjuvant. Anti-AChR antibody titers in C57BL/6 and C3H/He mice were significantly higher after challenge with AChR in DP-treated than in control mice. Augmented anti-AChR titers were not seen in strain A mice, but after 6 months of DP treatment increased susceptibility developed to the induction of experimental autoimmune myasthenia gravis. Nine weeks after challenge with purified AChR, 10 of 11 mice developed clinical weakness, leading to death in 6. Results of edrophonium testing were positive in 5 of 6 mice, and electrophysiological abnormalities were demonstrated in 3 of the surviving mice. Long-term DP treatment is associated with augmented anti-AChR antibody responses in C3H/He and C57BL/6 mice, and increased susceptibility to experimental autoimmune myasthenia gravis in strain A mice.
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Abstract
Lichen planus and primary biliary cirrhosis were seen in twenty-four patients. In seventeen patients, the cutaneous eruption followed the administration of D-penicillamine. In seven patients, lichen planus developed unrelated to therapy. Three of the latter group of patients were treated with D-penicillamine and had subsequent relapse or exacerbation of their preexisting lichen planus. The presence of lichen planus in patients with primary biliary cirrhosis and the propensity to develop this type of eruption while on D-penicillamine therapy are consistent with a graft-versus-host pathogenesis of primary biliary cirrhosis. Preexisting lichen planus should be regarded as a relative contraindication to the use of D-penicillamine in patients with primary biliary cirrhosis.
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Fawcett PR, McLachlan SM, Nicholson LV, Argov Z, Mastaglia FL. D-Penicillamine-associated myasthenia gravis: immunological and electrophysiological studies. Muscle Nerve 1982; 5:328-34. [PMID: 7099199 DOI: 10.1002/mus.880050409] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Immunological and electrophysiological features were investigated in a patient with rheumatoid arthritis who developed myasthenic symptoms after 10 months of treatment with D-penicillamine (D-pen). After an initial rise, acetylcholine receptor (AChR) antibodies gradually fell from 24.4 nmole alpha-bungarotoxin bound/liter to 1.8 nmole/liter following withdrawal of the drug, and this was associated with clinical and electrophysiological improvement. Immunoglobuline synthesis by peripheral blood lymphocytes cultured with pokeweed mitogen and D-pen was significantly increased at D-pen concentrations of 10-100 micrograms/ml in 2 patients with D-pen associated myasthenia gravis and 1 out of 3 normal individuals. Furthermore, lymphocytes from 1 myasthenic patient synthesized detectable AChR antibodies in vitro, and the amount of receptor antibody produced was increased in the presence of the drug. This effect was most marked at a concentration of 10 micrograms/ml which is thought to approximate the concentration in vivo. Our results confirm the in vivo findings of others that D-pen may have different effects on immunoglobulin production in different individuals and may also enhance the snythesis of at least 1 autoantibody, the AChR antibody.
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McVicker JH, Lava NS, Mittag TW, Ringel SP. D-penicillamine-induced neuromuscular disease in guinea pigs. Exp Neurol 1982; 76:46-57. [PMID: 7084364 DOI: 10.1016/0014-4886(82)90100-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Duncan CJ. Parallels between spontaneous release of transmitter at the neuromuscular junction and subcellular damage of muscle. Evidence for the underlying common involvement of intracellular Ca2+? COMPARATIVE BIOCHEMISTRY AND PHYSIOLOGY. A, COMPARATIVE PHYSIOLOGY 1982; 73:147-9. [PMID: 6128101 DOI: 10.1016/0300-9629(82)90047-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Burres SA, Kanter ME, Richman DP, Arnason BG. Studies on the pathophysiology of chronic D-penicillamine-induced myasthenia. Ann N Y Acad Sci 1981; 377:640-51. [PMID: 6951489 DOI: 10.1111/j.1749-6632.1981.tb33763.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
Disorders of neuromuscular transmission in humans are caused by a wide variety of agents including systemic diseases, drugs, environmental toxins, animal envenomation, cations, and hormones. Some are genetically determined. Many are of known etiology. All such disorders interfere with one or more events in the sequence whereby a nerve impulse excites a muscle action potential. In many disorders of neuromuscular transmission, abnormal fatigue occurs, and some cases respond dramatically to treatment. Investigation of the microphysiology, microanatomy, and pharmacology of both normal and diseased neuromuscular junctions has increased our knowledge of these disorders.
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Torres CF, Griggs RC, Baum J, Penn AS. Penicillamine-induced myasthenia gravis in progressive systemic sclerosis. ARTHRITIS AND RHEUMATISM 1980; 23:505-8. [PMID: 7370063 DOI: 10.1002/art.1780230414] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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