1
|
Arce MI, Breetz KA, Martin CA. Treatment of Depression in Adolescents With Myasthenia Gravis. Cureus 2024; 16:e58408. [PMID: 38756305 PMCID: PMC11098442 DOI: 10.7759/cureus.58408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2024] [Indexed: 05/18/2024] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disorder in which, most commonly, there is a production of autoantibodies against the nicotinic acetylcholinergic receptors at the neuromuscular junction, resulting in skeletal muscle weakness. For pediatric patients, literature addressing the psychiatric implications of MG and suitable treatment options for individuals with concurrent psychiatric illnesses is scarce. In this case report, an adolescent with MG and comorbid depression was treated following a suicide attempt via self-poisoning. The patient experienced an improvement of depressive symptoms upon initiating fluoxetine, despite concerns raised by previous studies suggesting that fluoxetine might block acetylcholine receptors at the neuromuscular junction with varying degrees of affinity, potentially worsening MG symptoms. In this case, our patient exhibited sustained control of her MG symptoms without exacerbation once she was started on fluoxetine. This case highlights the value of further investigation into the safety and efficacy of selective serotonin reuptake inhibitors (SSRIs) in the management of depression among pediatric patients with MG.
Collapse
Affiliation(s)
- Mariana I Arce
- Department of Child Psychiatry, University of Kentucky College of Medicine, Lexington, USA
| | - Katherine A Breetz
- Department of Child Psychiatry, University of Kentucky College of Medicine, Lexington, USA
| | | |
Collapse
|
2
|
Mihalache OA, Vilciu C, Petrescu DM, Petrescu C, Manea MC, Ciobanu AM, Ciobanu CA, Popa-Velea O, Riga S. Depression: A Contributing Factor to the Clinical Course in Myasthenia Gravis Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:56. [PMID: 38256317 PMCID: PMC10819146 DOI: 10.3390/medicina60010056] [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: 12/07/2023] [Revised: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: The association between myasthenia gravis (MG) and depression is intricate and characterized by bidirectional causality. In this regard, MG can be a contributing factor to depression and, conversely, depression may worsen the symptoms of MG. This study aimed to identify any differences in the progression of the disease among patients with MG who were also diagnosed with depression as compared to those without depression. Our hypothesis focused on the theory that patients with more severe MG symptoms may have a higher likelihood of suffering depression at the same time. Materials and Methods: One hundred twenty-two male and female patients (N = 122) aged over 18 with a confirmed diagnosis of autoimmune MG who were admitted to the Neurology II department of Myasthenia Gravis, Clinical Institute Fundeni in Bucharest between January 2019 and December 2020, were included in the study. Patients were assessed at baseline and after six months. The psychiatric assessment of the patients included the Hamilton Depression Rating Scale-17 items (HAM-D), and neurological status was determined with two outcome measures: Quantitative Myasthenia Gravis (QMG) and Myasthenia Gravis Activities of Daily Life (MG-ADL). The patients were divided into two distinct groups as follows: group MG w/dep, which comprised 49 MG patients diagnosed with depressive disorder who were also currently receiving antidepressant medication, and group MG w/o dep, which consisted of 73 patients who did not have depression. Results: In our study, 40.16% of the myasthenia gravis (MG) patients exhibited a comorbid diagnosis of depression. Among the MG patients receiving antidepressant treatment, baseline assessments revealed a mean MG-ADL score of 7.73 (SD = 5.05), an average QMG score of 18.40 (SD = 8.61), and a mean Ham-D score of 21.53 (SD = 7.49). After a six-month period, a statistically significant decrease was observed in the MG-ADL (2.92, SD = 1.82), QMG (7.15, SD = 4.46), and Ham-D scores (11.16, SD = 7.49) (p < 0.0001). These results suggest a significant correlation between MG severity and elevated HAM-D depression scores. Regarding the MG treatment in the group with depression, at baseline, the mean dose of oral corticosteroids was 45.10 mg (SD = 16.60). Regarding the treatment with pyridostigmine, patients with depression and undergoing antidepressant treatment remained with an increased need for pyridostigmine, 144.49 mg (SD = 51.84), compared to those in the group without depression, 107.67 mg (SD = 55.64, p < 0.001). Conclusions: Our investigation confirms that the occurrence of depressive symptoms is significantly widespread among individuals diagnosed with MG. Disease severity, along with younger age and higher doses of cortisone, is a significant factor associated with depression in patients with MG. Substantial reductions in MG-ADL and QMG scores were observed within each group after six months, highlighting the effectiveness of MG management. The findings suggest that addressing depressive symptoms in MG patients, in addition to standard MG management, can lead to improved clinical outcomes.
Collapse
Affiliation(s)
- Oana Antonia Mihalache
- Department of Doctoral Studies, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Neurology, “Fundeni” Clinical Institute, 022328 Bucharest, Romania;
| | - Crisanda Vilciu
- Department of Neurology, “Fundeni” Clinical Institute, 022328 Bucharest, Romania;
- Department of Neurology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Diana-Mihaela Petrescu
- Department of Neurology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Cristian Petrescu
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania; (C.P.); (M.C.M.)
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
| | - Mihnea Costin Manea
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania; (C.P.); (M.C.M.)
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
| | - Adela Magdalena Ciobanu
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania; (C.P.); (M.C.M.)
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
| | | | - Ovidiu Popa-Velea
- Department of Medical Psychology, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania;
| | - Sorin Riga
- Department of Stress Research and Prophylaxis, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania;
- Romanian Academy of Medical Sciences, 927180 Bucharest, Romania
| |
Collapse
|
3
|
D’Alessandro R, Salvalaggio A, Vacchetti M, Mongini TE, Ricci FS. Juvenile Myasthenia Gravis in a 14-year-old adolescent masked by mood disorder: the complex balance between neurology and psychiatry. ACTA MYOLOGICA : MYOPATHIES AND CARDIOMYOPATHIES : OFFICIAL JOURNAL OF THE MEDITERRANEAN SOCIETY OF MYOLOGY 2022; 41:126-129. [PMID: 36349182 PMCID: PMC9628800 DOI: 10.36185/2532-1900-079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
Juvenile Myasthenia Gravis (JMG) is a neuromuscular disease, often characterized at onset by fatigue and fluctuating weakness. We report a case of a girl affected by severe mood disorder, in which the diagnosis of JMG and its treatment were challenged by the concomitant psychiatric condition. A 14-year-old girl, with a history of severe mood disorder and emotional dysregulation, had been treated with benzodiazepines, sertraline, and antipsychotics, reporting generalized fatigability, weakness, and drowsiness, first ascribed to her psychiatric condition and therapy. After a suicide attempt, she was hospitalized and a neurological assessment revealed a fluctuating ptosis and facial weakness, that improved with rest. The diagnosis of JMG was confirmed by repeated nerve stimulation test, and by the response to pyridostigmine. Antibodies anti-AChR and anti-MuSK were negative. JMG diagnosis may be harder in adolescents with psychiatric comorbidity. Moreover, the neurological condition limits the choice of the appropriate psychopharmacotherapy.
Collapse
Affiliation(s)
- Rossella D’Alessandro
- Section of Child and Adolescent Neuropsychiatry, Department of Public Health, and Paediatric Sciences, Università degli Studi di Torino, Turin, Italy
| | - Anna Salvalaggio
- Section of Child and Adolescent Neuropsychiatry, Department of Public Health, and Paediatric Sciences, Università degli Studi di Torino, Turin, Italy
| | - Martina Vacchetti
- Section of Child and Adolescent Neuropsychiatry, Department of Public Health, and Paediatric Sciences, Università degli Studi di Torino, Turin, Italy
| | - Tiziana E. Mongini
- Neuromuscular Unit, Department of Neurosciences RLM, University of Turin, Turin, Italy
| | - Federica S. Ricci
- Section of Child and Adolescent Neuropsychiatry, Department of Public Health, and Paediatric Sciences, Università degli Studi di Torino, Turin, Italy
| |
Collapse
|
4
|
Ungureanu A, van der Meer J, Bicvic A, Abbuehl L, Chiffi G, Jaques L, Suter-Riniker F, Leib SL, Bassetti CLA, Dietmann A. Meningitis, meningoencephalitis and encephalitis in Bern: an observational study of 258 patients. BMC Neurol 2021; 21:474. [PMID: 34872509 PMCID: PMC8647376 DOI: 10.1186/s12883-021-02502-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 11/25/2021] [Indexed: 12/05/2022] Open
Abstract
Background Depending on geographic location, causes of encephalitis, meningoencephalitis and meningitis vary substantially. We aimed to identify the most frequent causes, clinical presentation and long-term outcome of encephalitis, meningoencephalitis and meningitis cases treated in the Inselspital University Hospital Bern, Switzerland. Methods In this monocentric, observational study, we performed a retrospective review of clinical patient records for all patients treated within a 3-year period. Patients were contacted for a telephone follow-up interview and to fill out questionnaires, especially related to disturbances of sleep and wakefulness. Results We included 258 patients with the following conditions: encephalitis (18%), nonbacterial meningoencephalitis (42%), nonbacterial meningitis (27%) and bacterial meningoencephalitis/meningitis (13%). Herpes simplex virus (HSV) was the most common cause of encephalitis (18%); tick-borne encephalitis virus (TBEV) was the most common cause of nonbacterial meningoencephalitis (46%), enterovirus was the most common cause of nonbacterial meningitis (21%) and Streptococcus pneumoniae was the most common cause of bacterial meningoencephalitis/meningitis (49%). Overall, 35% patients remained without a known cause. After a median time of 16 months, 162 patients participated in the follow-up interview; 56% reported suffering from neurological long-term sequelae such as fatigue and/or excessive daytime sleepiness (34%), cognitive impairment and memory deficits (22%), headache (14%) and epileptic seizures (11%). Conclusions In the Bern region, Switzerland, TBEV was the overall most frequently detected infectious cause, with a clinical manifestation of meningoencephalitis in the majority of cases. Long-term neurological sequelae, most importantly cognitive impairment, fatigue and headache, were frequently self-reported not only in encephalitis and meningoencephalitis survivors but also in viral meningitis survivors up to 40 months after acute infection. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02502-3.
Collapse
Affiliation(s)
- Anamaria Ungureanu
- Department of Neurology, University Hopsital and University of Bern, Inselspital, Bern, Switzerland
| | - Julia van der Meer
- Department of Neurology, University Hopsital and University of Bern, Inselspital, Bern, Switzerland
| | - Antonela Bicvic
- Department of Neurology, University Hopsital and University of Bern, Inselspital, Bern, Switzerland
| | - Lena Abbuehl
- Department of Neurology, University Hopsital and University of Bern, Inselspital, Bern, Switzerland
| | - Gabriele Chiffi
- Institute for Infectious Disease, University of Bern, Bern, Switzerland
| | - Léonore Jaques
- Department of Neurology, University Hopsital and University of Bern, Inselspital, Bern, Switzerland
| | | | - Stephen L Leib
- Institute for Infectious Disease, University of Bern, Bern, Switzerland
| | - Claudio L A Bassetti
- Department of Neurology, University Hopsital and University of Bern, Inselspital, Bern, Switzerland
| | - Anelia Dietmann
- Department of Neurology, University Hopsital and University of Bern, Inselspital, Bern, Switzerland.
| |
Collapse
|
5
|
Causes of symptom dissatisfaction in patients with generalized myasthenia gravis. J Neurol 2021; 269:3086-3093. [PMID: 34806129 DOI: 10.1007/s00415-021-10902-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patient-centered assessments have attracted increasing attention in the last decade in clinics and research. The purpose of this study was to examine the association between patients' satisfaction with symptoms and several disease-specific and generic outcome measures in 100 patients with generalized myasthenia gravis (gMG). METHODS In this cross-sectional study, patients with gMG followed at the Copenhagen Neuromuscular Center from October 2019 to June 2020 participated in one test. The patients completed commonly used MG-specific outcome measures and generic questionnaires for depression (Major Depression Inventory), comorbidities (Charlson Comorbidity Index), fatigue (Multidimensional Fatigue Inventory), overall health state (EQ-5D-3L), and satisfaction with MG treatment. The analyses were anchored in the Patient Acceptable Symptom State (PASS). RESULTS N = 190 patients were screened for the study, and 100 patients were included. One-third of the patients reported dissatisfaction (negative PASS status) with the current symptom state. Increasing MG symptoms, fatigue, depression, low MG-related quality of life, and shorter disease duration were associated with negative PASS status. Age, sex, BMI, MG treatment, and comorbidity did not influence PASS status. CONCLUSIONS This study shows that dissatisfaction with the current symptom level is high in patients with gMG and that dissatisfaction is associated with disease severity, disease length, depression, fatigue, and lower MG-related quality of life. The results emphasize the importance of a patient-centered approach to MG treatment to optimize patient satisfaction. The PASS question was useful in this study to investigate the causes of symptom dissatisfaction in gMG.
Collapse
|
6
|
Gilhus NE, Verschuuren JJGM, Hovland SIB, Simmonds H, Groot F, Palace J. Myasthenia gravis: do not forget the patient perspective. Neuromuscul Disord 2021; 31:S0960-8966(21)00583-6. [PMID: 34635387 DOI: 10.1016/j.nmd.2021.07.396] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/09/2021] [Accepted: 07/20/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Norway; Department of Neurology, Haukeland University Hospital, Bergen, Norway.
| | | | | | - Huw Simmonds
- Myaware, College Business Centre, Derby, England
| | - Floor Groot
- Dutch Neuromuscular disease Association, Baarn, The Netherlands
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, University of Oxford, Hospitals Trust, Oxford, England
| |
Collapse
|
7
|
Abstract
ABSTRACT This update covers recommendations for myasthenia gravis (MG) in patients with coronavirus 2019 disease as well as reports of the clinical features of patients with MG and coronavirus 2019. Updated advisory committee recommendations for the use of thymectomy in generalized MG are also provided. Other MG topics include lipoprotein receptor-4 and agrin antibody associations, factors influencing conversion of ocular to generalized MG, the use of rituximab for more recent onset disease, immunoglobulins for maintenance therapy, and fatigue and depression.
Collapse
Affiliation(s)
- David Lacomis
- Departments of Neurology and Pathology (Neuropathology), University of Pittsburgh School of Medicine, Pittsburgh, PA; and
| | - Gil I Wolfe
- Department of Neurology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences/SUNY, Buffalo, NY
| |
Collapse
|
8
|
Kreis OA, Alekseeva TM, Gavrilov YV, Valko PO, Valko Y. Diagnosis of sleepiness, fatigue and depression in patients with myasthenia gravis. ACTA ACUST UNITED AC 2020. [DOI: 10.17650/2222-8721-2020-10-4-27-37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction. Examination of excessive daytime sleepiness, fatigue and depression in patients with myasthenia gravis is important for differential diagnosis of other disorders, and adds to a comprehensive clinical assessment.Objective. The aim is a comprehensive assessment of sleepiness, fatigue and depression and evaluation of the impact of autoimmune comorbidity on these symptoms in myasthenia gravis patients, using newly validated Russian versions of international questionnaires. The present article aims at familiarizing a wider Russian-speaking audience of specialists in the field of neuromuscular disease and sleep medicine with the main findings of our previously published work.Materials and methods. The study included 73 patients with MG and 230 control subjects. For sleepiness, fatigue and depression evaluation were used: Fatigue Severity Scale (FSS), Fatigue Impact Scale (FIS) (cognitive / physical / psychosocial subscales), Epworth Sleepiness Scale (ESS), Beck Depression Inventory (BDI) (cognitive-affective and somatic domains), Spielberger–Khanin State Trait Anxiety Inventory (STAI).Results. The Fatigue Severity Scale and Fatigue Impact Scale showed good psychometric properties and can be used to identify distinct aspects of fatigue in patients with myasthenia gravis. The studied patient cohort revealed clinically significant fatigue (69.9 %), excessive daytime sleepiness (15.1 %), moderate to severe depression (20.5 %), a high level of personal (64.4 %) and situational anxiety (27.4 %). Among 13 patients with myasthenia gravis and additional autoimmune comorbidity, there were no significant differences in the severity of sleepiness, fatigue and depression compared with the main group.Conclusion. The use of self-reported scale of sleepiness, fatigue and depression combined with careful clinical-neurological characterization adds to a more comprehensive view of the patient. The identification of sleepiness, fatigue and depression can guide therapeutic decisions and contributes to a better patient care. The presence of concomitant autoimmune pathology in patients with myasthenia gravis does not seem to increase the severity of sleepiness, fatigue and depression.
Collapse
Affiliation(s)
- O. A. Kreis
- Almazov National Medical Research Centre, the Ministry of Health of Russia; North-Western State Medical University, the Ministry of Health of Russia
| | - T. M. Alekseeva
- Almazov National Medical Research Centre, the Ministry of Health of Russia
| | | | - P. O. Valko
- University Hospital Zurich, University of Zurich
| | - Yu. Valko
- University Hospital Zurich, University of Zurich
| |
Collapse
|