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Gromadzka G, Czerwińska J, Krzemińska E, Przybyłkowski A, Litwin T. Wilson's Disease-Crossroads of Genetics, Inflammation and Immunity/Autoimmunity: Clinical and Molecular Issues. Int J Mol Sci 2024; 25:9034. [PMID: 39201720 PMCID: PMC11354778 DOI: 10.3390/ijms25169034] [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: 07/19/2024] [Revised: 08/11/2024] [Accepted: 08/13/2024] [Indexed: 09/03/2024] Open
Abstract
Wilson's disease (WD) is a rare, autosomal recessive disorder of copper metabolism caused by pathogenic mutations in the ATP7B gene. Cellular copper overload is associated with impaired iron metabolism. Oxidative stress, cuproptosis, and ferroptosis are involved in cell death in WD. The clinical picture of WD is variable. Hepatic/neuropsychiatric/other symptoms may manifest in childhood/adulthood and even old age. It has been shown that phenotypic variability may be determined by the type of ATP7B genetic variants as well as the influence of various genetic/epigenetic, environmental, and lifestyle modifiers. In 1976, immunological abnormalities were first described in patients with WD. These included an increase in IgG and IgM levels and a decrease in the percentage of T lymphocytes, as well as a weakening of their bactericidal effect. Over the following years, it was shown that there is a bidirectional relationship between copper and inflammation. Changes in serum cytokine concentrations and the relationship between cytokine gene variants and the clinical course of the disease have been described in WD patients, as well as in animal models of this disease. Data have also been published on the occurrence of antinuclear antibodies (ANAs), antineutrophil cytoplasmic antibodies (ANCAs), anti-muscle-specific tyrosine kinase antibodies, and anti-acetylcholine receptor antibodies, as well as various autoimmune diseases, including systemic lupus erythematosus (SLE), myasthenic syndrome, ulcerative colitis, multiple sclerosis (MS), polyarthritis, and psoriasis after treatment with d-penicillamine (DPA). The occurrence of autoantibodies was also described, the presence of which was not related to the type of treatment or the form of the disease (hepatic vs. neuropsychiatric). The mechanisms responsible for the occurrence of autoantibodies in patients with WD are not known. It has also not been clarified whether they have clinical significance. In some patients, WD was differentiated or coexisted with an autoimmune disease, including autoimmune hepatitis or multiple sclerosis. Various molecular mechanisms may be responsible for immunological abnormalities and/or the inflammatory processes in WD. Their better understanding may be important for explaining the reasons for the diversity of symptoms and the varied course and response to therapy, as well as for the development of new treatment regimens for WD.
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Affiliation(s)
- Grażyna Gromadzka
- Department of Biomedical Sciences, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszynski University, Wóycickiego Street 1/3, 01-938 Warsaw, Poland
| | - Julia Czerwińska
- Students Scientific Association “Immunis”, Cardinal Stefan Wyszynski University, Dewajtis Street 5, 01-815 Warsaw, Poland
| | - Elżbieta Krzemińska
- Students Scientific Association “Immunis”, Cardinal Stefan Wyszynski University, Dewajtis Street 5, 01-815 Warsaw, Poland
| | - Adam Przybyłkowski
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland;
| | - Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego Street 9, 02-957 Warsaw, Poland;
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He T, Chen K, Li Y, Luo Z, Luo M, Yang H. Clinical Features and Prognostic Analysis of MuSK-Antibody-Positive Myasthenia Gravis versus Double-Seropositive Myasthenia Gravis: A Single-Center Study from Central South China. Neuropsychiatr Dis Treat 2024; 20:725-735. [PMID: 38566882 PMCID: PMC10986406 DOI: 10.2147/ndt.s450651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 03/13/2024] [Indexed: 04/04/2024] Open
Abstract
Purpose To decipher the discrepancies between muscle-specific kinase antibody-positive myasthenia gravis (MuSK-MG) and double-seropositive myasthenia gravis (DSP-MG), and to determine prognostic factors for minimal manifestation status (MMS) achievement in MG patients with MuSK autoantibodies (MuSK-Ab). Patients and Methods A total of 34 MG patients seropositive for MuSK-Ab were enrolled in this study. The demographic and clinical features were compared between MuSK-MG (n = 28) and DSP-MG (n = 6) patients, and factors affecting MMS induction in all patients with MuSK-Ab were identified using Cox regression analysis. Results Compared to MuSK-MG patients, those with DSP-MG had similar clinical characteristics, except that they had a lower frequency of bulbar muscle involvement at nadir (50% vs 92.9%; P = 0.029) and higher proportions of comorbidities with diabetes mellitus (33.3% vs 0%; P = 0.027) and thymic abnormalities (33.3% vs 0%; P = 0.027). Higher MG Activities of Daily Living (MG-ADL) scores (HR = 0.16, 95% CI: 0.037-0.7, P = 0.015) and axial muscle involvement at nadir (HR = 0.39, 95% CI: 0.16-0.94, P = 0.035) were negative prognostic factors for MMS achievement in patients with MuSK-Ab regardless of acetylcholine receptor antibody (AChR-Ab) positivity. Multivariable Cox regression analysis further established higher MG-ADL scores at the nadir (HR = 0.19, 95% CI: 0.04-0.94; P = 0.042) as an independent risk factor for MMS achievement. Conclusion DSP-MG was comparable to MuSK-MG and could be considered a single entity in our cohort. In all MG patients with MuSK-Ab, a higher MG-ADL score at nadir may herald a lower chance of MMS achievement, with no observed potential effect of AChR-Ab presence.
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Affiliation(s)
- Ting He
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People’s Republic of China
| | - Kangzhi Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People’s Republic of China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People’s Republic of China
| | - Zhaohui Luo
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People’s Republic of China
| | - Mengchuan Luo
- Department of Geriatrics, Xiangya Hospital, Central South University, Changsha, 410008, People’s Republic of China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, People’s Republic of China
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Antos A, Członkowska A, Bembenek J, Kurkowska-Jastrzębska I, Litwin T. D-Penicillamine-Induced Myasthenia Gravis-A Probable Complication of Wilson's Disease Treatment-A Case Report and Systematic Review of the Literature. Life (Basel) 2023; 13:1715. [PMID: 37629572 PMCID: PMC10455431 DOI: 10.3390/life13081715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/31/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Wilson's disease (WD) is a genetic disorder with copper accumulation in various tissues leading to related clinical symptoms (mainly hepatic and neuropsychiatric) which can be in 85% of patients successfully treated with anti-copper agents. However, during WD treatment neurological deterioration may occur in several patients. D-penicillamine (DPA) is one of the most frequently used drugs in WD treatment. Despite its efficacy, DPA can produce many adverse drug reactions, which should be recognized early. We present the case of a 51-year-old man diagnosed with the hepatic form of WD and initially treated with DPA in whom after 15 months of treatment, diplopia and evening ptosis occurred. WD treatment non-compliance as well as overtreatment were excluded. Supported by neurological symptoms, a positive edrophonium test, and high serum levels of antibodies against acetylcholine receptors (AChR-Abs), as well as low concentrations of antibodies against muscle-specific kinase (MuSK-Abs), the diagnosis of myasthenia gravis (MG), induced by DPA, was established. DPA was stopped; zinc sulfate for WD and pyridostigmine for MG symptoms were introduced. Diplopia and ptosis subsided after a few days, which supported our diagnosis. During a follow-up visit after 6 months, the patient did not present any MG symptoms. AChR-Abs level gradually decreased and MuSK-Abs were no longer detected. Pyridostigmine was stopped, and within 9 months of follow-up, the neurological symptoms of MG did not reoccur. The authors discussed the patient's neurological deterioration, performed a systematic review of DPA-induced MG in WD and concluded that MG is a rare and usually reversible complication of DPA treatment. DPA-induced MG generally occurs 2-12 months after treatment initiation and ocular symptoms predominate. Response to pyridostigmine treatment is good and MG symptoms usually reverse within one year after DPA treatment cessation. However, symptoms may persist in some cases where DPA treatment is only a trigger factor for MG occurrence.
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Affiliation(s)
- Agnieszka Antos
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (A.A.); (A.C.); (I.K.-J.)
| | - Anna Członkowska
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (A.A.); (A.C.); (I.K.-J.)
| | - Jan Bembenek
- Department of Clinical Neurophysiology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland;
| | - Iwona Kurkowska-Jastrzębska
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (A.A.); (A.C.); (I.K.-J.)
| | - Tomasz Litwin
- Second Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland; (A.A.); (A.C.); (I.K.-J.)
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Vakrakou AG, Karachaliou E, Chroni E, Zouvelou V, Tzanetakos D, Salakou S, Papadopoulou M, Tzartos S, Voumvourakis K, Kilidireas C, Giannopoulos S, Tsivgoulis G, Tzartos J. Immunotherapies in MuSK-positive Myasthenia Gravis; an IgG4 antibody-mediated disease. Front Immunol 2023; 14:1212757. [PMID: 37564637 PMCID: PMC10410455 DOI: 10.3389/fimmu.2023.1212757] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/05/2023] [Indexed: 08/12/2023] Open
Abstract
Muscle-specific kinase (MuSK) Myasthenia Gravis (MG) represents a prototypical antibody-mediated disease characterized by predominantly focal muscle weakness (neck, facial, and bulbar muscles) and fatigability. The pathogenic antibodies mostly belong to the immunoglobulin subclass (Ig)G4, a feature which attributes them their specific properties and pathogenic profile. On the other hand, acetylcholine receptor (AChR) MG, the most prevalent form of MG, is characterized by immunoglobulin (Ig)G1 and IgG3 antibodies to the AChR. IgG4 class autoantibodies are impotent to fix complement and only weakly bind Fc-receptors expressed on immune cells and exert their pathogenicity via interfering with the interaction between their targets and binding partners (e.g. between MuSK and LRP4). Cardinal differences between AChR and MuSK-MG are the thymus involvement (not prominent in MuSK-MG), the distinct HLA alleles, and core immunopathological patterns of pathology in neuromuscular junction, structure, and function. In MuSK-MG, classical treatment options are usually less effective (e.g. IVIG) with the need for prolonged and high doses of steroids difficult to be tapered to control symptoms. Exceptional clinical response to plasmapheresis and rituximab has been particularly observed in these patients. Reduction of antibody titers follows the clinical efficacy of anti-CD20 therapies, a feature implying the role of short-lived plasma cells (SLPB) in autoantibody production. Novel therapeutic monoclonal against B cells at different stages of their maturation (like plasmablasts), or against molecules involved in B cell activation, represent promising therapeutic targets. A revolution in autoantibody-mediated diseases is pharmacological interference with the neonatal Fc receptor, leading to a rapid reduction of circulating IgGs (including autoantibodies), an approach already suitable for AChR-MG and promising for MuSK-MG. New precision medicine approaches involve Chimeric autoantibody receptor T (CAAR-T) cells that are engineered to target antigen-specific B cells in MuSK-MG and represent a milestone in the development of targeted immunotherapies. This review aims to provide a detailed update on the pathomechanisms involved in MuSK-MG (cellular and humoral aberrations), fostering the understanding of the latest indications regarding the efficacy of different treatment strategies.
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Affiliation(s)
- Aigli G. Vakrakou
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Karachaliou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elisabeth Chroni
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | - Vasiliki Zouvelou
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tzanetakos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavroula Salakou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Papadopoulou
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Physiotherapy, University of West Attica, Athens, Greece
| | - Socrates Tzartos
- Tzartos NeuroDiagnostics, Athens, Greece
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
- Department of Pharmacy, University of Patras, Patras, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- First Department of Neurology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, Henry Dunant Hospital Center, Athens, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - John Tzartos
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Pugliese A, Nicocia G, Messina S, Toscano A, Rodolico C. A very late onset AChR and MuSK double positive myasthenia gravis: a case description and literature review. Neuromuscul Disord 2023; 33:145-147. [PMID: 36628839 DOI: 10.1016/j.nmd.2022.12.004] [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: 04/19/2021] [Revised: 11/06/2022] [Accepted: 12/12/2022] [Indexed: 12/14/2022]
Abstract
AChR and MuSK double positive myasthenia gravis has been rarely reported. Generally, it occurs in children and adults after thymectomy or immunotherapy. Furthermore, in a few patients with bulbar or respiratory involvement, MuSK antibodies might be detected after clinical deterioration. We report a man with a very late onset myasthenia gravis (86-year-old) and the coexistence of both antibodies at the time of the diagnosis. Despite the presence of MuSK antibodies, he manifested no bulbar symptoms and had a favorable clinical outcome. However, side effects related to low dose pyridostigmine were evident. Hence, double positivity can also occur in elderly and in more benign forms of myasthenia gravis. Other cases of AChR and MuSK double positive myasthenia gravis could allow a better definition of this condition.
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Affiliation(s)
- A Pugliese
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - G Nicocia
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - S Messina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - A Toscano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - C Rodolico
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
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Chung HY, Kim MJ, Kim SW, Oh J, Shin HY. Development and Application of a Cell-Based Assay for LRP4 Antibody Associated With Myasthenia Gravis. J Clin Neurol 2023; 19:60-66. [PMID: 36606647 PMCID: PMC9833872 DOI: 10.3988/jcn.2023.19.1.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE Among patients with double-seronegative myasthenia gravis (dSN-MG) who do not have detectable antibodies against acetylcholine receptor or muscle-specific tyrosine kinase, autoantibodies against low-density lipoprotein receptor-related protein 4 (LRP4-Ab) have been detected recently. The purpose of this study was to develop an in-house cell-based assay (CBA) to detect LRP4-Ab and to apply it to samples from patients with MG. METHODS The complementary DNA of LRP4 fused into a vector plasmid containing GFP was transfected into human embryonic kidney 293 (HEK293) cells. LRP4 expression in the transfected HEK293 cells was assessed using the reverse-transcription polymerase chain reaction (RT-PCR), Western blotting, and immunocytochemistry. The CBA included 252 sera collected from 202 patients with MG and 38 with other neuromuscular diseases, and 12 healthy controls. The transfected HEK293 cells were incubated using sera and antihuman immunoglobulin G antibodies conjugated with Alexa Fluor 594. The presence of LRP4-Ab was determined based on the fluorescence intensity and the localization in fluorescence microscopy. RESULTS The expressions of the mRNA and protein of LRP4 in the transfected HEK293 cells were confirmed using RT-PCR and Western blotting, respectively. Immunocytochemistry indicated LPR4 expression on the cell membrane. Among 202 patients with MG including 53 with dSN-MG, LRP4-Ab were positive in 3 patients who were all double seronegative. LRP4-Ab were not detected in the patients with other neuromuscular diseases or the healthy controls. CONCLUSIONS A CBA for detecting LRP4-Ab associated with MG has been developed, and was used to find LRP4-Ab in the sera of patients with MG.
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Affiliation(s)
- Hye Yoon Chung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Min Ju Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.,Graduate Program of Nano Science and Technology, Yonsei University, Seoul, Korea
| | - Seung Woo Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jeeyoung Oh
- Department of Neurology, Konkuk University Medical Center, School of Medicine, Konkuk University, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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Antczak‐Kowalska M, Członkowska A, Eyileten C, Palejko A, Cudna A, Wolska M, Piechal A, Litwin T. Autoantibodies in Wilson disease: Impact on clinical course. JIMD Rep 2022; 63:508-517. [PMID: 36101827 PMCID: PMC9458613 DOI: 10.1002/jmd2.12317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 07/02/2022] [Accepted: 07/11/2022] [Indexed: 11/21/2022] Open
Abstract
Symptoms of Wilson disease (WD) vary and additional factors such as autoimmunity may play an important role in WD pathogenesis. The presence of antinuclear antibodies (ANA), anti-neutrophil cytoplasmic antibodies, neuronal surface antibodies, and onconeural antibodies in WD was investigated using standardized indirect immunofluorescence assays and Western Blot analysis. The presence of all studied autoantibodies was higher in WD patients in comparison to healthy subjects, but there was no statistically significant difference in autoantibodies frequency according to disease manifestation. D-penicillamine treatment was associated with a higher presence of ANA than zinc sulfate but without an increase in autoimmune diseases rate.
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Affiliation(s)
| | - Anna Członkowska
- 2nd Department of NeurologyInstitute of Psychiatry and NeurologyWarsawPoland
| | - Ceren Eyileten
- Center for Preclinical Research and Technology CEPT, Department of Experimental and Clinical PharmacologyMedical University of WarsawWarsawPoland
| | - Anna Palejko
- 2nd Department of NeurologyInstitute of Psychiatry and NeurologyWarsawPoland
| | - Agnieszka Cudna
- 2nd Department of NeurologyInstitute of Psychiatry and NeurologyWarsawPoland
- Center for Preclinical Research and Technology CEPT, Department of Experimental and Clinical PharmacologyMedical University of WarsawWarsawPoland
| | - Marta Wolska
- Center for Preclinical Research and Technology CEPT, Department of Experimental and Clinical PharmacologyMedical University of WarsawWarsawPoland
- Doctoral School, Medical University of WarsawWarsawPoland
| | - Agnieszka Piechal
- 2nd Department of NeurologyInstitute of Psychiatry and NeurologyWarsawPoland
- Center for Preclinical Research and Technology CEPT, Department of Experimental and Clinical PharmacologyMedical University of WarsawWarsawPoland
| | - Tomasz Litwin
- 2nd Department of NeurologyInstitute of Psychiatry and NeurologyWarsawPoland
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Avan A, Członkowska A, Gaskin S, Granzotto A, Sensi SL, Hoogenraad TU. The Role of Zinc in the Treatment of Wilson’s Disease. Int J Mol Sci 2022; 23:ijms23169316. [PMID: 36012580 PMCID: PMC9409413 DOI: 10.3390/ijms23169316] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/09/2022] [Accepted: 08/15/2022] [Indexed: 02/06/2023] Open
Abstract
Wilson’s disease (WD) is a hereditary disorder of copper metabolism, producing abnormally high levels of non-ceruloplasmin-bound copper, the determinant of the pathogenic process causing brain and hepatic damage and dysfunction. Although the disease is invariably fatal without medication, it is treatable and many of its adverse effects are reversible. Diagnosis is difficult due to the large range and severity of symptoms. A high index of suspicion is required as patients may have only a few of the many possible biomarkers. The genetic prevalence of ATP7B variants indicates higher rates in the population than are currently diagnosed. Treatments have evolved from chelators that reduce stored copper to zinc, which reduces the toxic levels of circulating non-ceruloplasmin-bound copper. Zinc induces intestinal metallothionein, which blocks copper absorption and increases excretion in the stools, resulting in an improvement in symptoms. Two meta-analyses and several large retrospective studies indicate that zinc is equally effective as chelators for the treatment of WD, with the advantages of a very low level of toxicity and only the minor side effect of gastric disturbance. Zinc is recommended as a first-line treatment for neurological presentations and is gaining acceptance for hepatic presentations. It is universally recommended for lifelong maintenance therapy and for presymptomatic WD.
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Affiliation(s)
- Abolfazl Avan
- Department of Public Health, School of Medicine, Mashhad University of Medical Sciences, Mashhad 93518-88415, Iran
- Correspondence:
| | - Anna Członkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, 02-957 Warsaw, Poland
| | - Susan Gaskin
- Department of Civil Engineering, McGill University, Montreal, QC H3A 0C3, Canada
| | - Alberto Granzotto
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Department of Neuroscience, Imaging, and Clinical Sciences (DNISC), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Sue and Bill Gross Stem Cell Research Center, University of California-Irvine, Irvine, CA 92697, USA
| | - Stefano L. Sensi
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Department of Neuroscience, Imaging, and Clinical Sciences (DNISC), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Institute for Advanced Biomedical Technologies (ITAB), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Tjaard U. Hoogenraad
- Department of Neurology, University Medical Centre Utrecht, 3584 CX Utrecht, The Netherlands
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Thapa L, Thapa M, Bhattarai S, Shrestha AM, Sharma N, Rai N, Pokharel M, Paudel R. D-penicillamine Induced Myasthenia Gravis in Wilson's Disease: A Case Report. JNMA J Nepal Med Assoc 2022; 60:644-647. [PMID: 36705187 PMCID: PMC9297353 DOI: 10.31729/jnma.7607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/25/2022] [Indexed: 01/31/2023] Open
Abstract
Myasthenia gravis is a neuromuscular junction disorder characterised by fluctuating muscle weakness, improved by using anti-cholinesterase drugs. In addition to the autoimmune aetiology, various factors such as infections, surgery, and drugs are known to precipitate the condition. We report a case of a 15-year-old boy with D-penicillamine-induced myasthenia gravis who presented with facial diplegia, dysphagia, and drooling of saliva, 6 years after the initiation of treatment for Wilson's disease. Therefore, clinicians should be more vigilant while prescribing patients with chelating drugs like D-penicillamine with regular monitoring of the new symptoms and keeping a very low threshold for the suspicion of myasthenia gravis. Keywords d-penicillamine; myasthenia gravis; pyridostigmine; Wilson's disease.
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Affiliation(s)
- Lekhjung Thapa
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal,Correspondence: Dr Lekhjung Thapa, Department of Neurology, National Neuro Centre, Maharajgunj, Kathmandu, Nepal. , Phone: +977-9749370390
| | - Monika Thapa
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Suman Bhattarai
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Abhishek Man Shrestha
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Nooma Sharma
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Nilshan Rai
- KIST Medical College and Teaching Hospital, Imadol, Lalitpur, Nepal
| | - Merina Pokharel
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Raju Paudel
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
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Ziogas DC, Mandellos D, Theocharopoulos C, Lialios PP, Bouros S, Ascierto PA, Gogas H. Neuromuscular Complications of Targeted Anticancer Agents: Can Tyrosine Kinase Inhibitors Induce Myasthenia Gravis? Getting Answers From a Case Report up to a Systematic Review. Front Oncol 2021; 11:727010. [PMID: 34722270 PMCID: PMC8554100 DOI: 10.3389/fonc.2021.727010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/23/2021] [Indexed: 11/29/2022] Open
Abstract
More than 40 tyrosine kinase inhibitors (TKIs) have received hematological or oncological indications over the past 20 years, following the approval of imatinib, and many others are currently being tested in clinical and preclinical level. Beyond their common toxicities, no certain agent from this large class of molecularly targeted therapies was strongly associated with “off-target” impairment of neuromuscular transmission, and although myasthenia gravis (MG) is a well-characterized autoimmune disorder, only few sporadic events proven by serologically detected causative autoantibodies and/or by positive electrophysiological tests are reported in the literature. Herein, we present the first case of anti-MUSK (+) MG in a woman with metastatic BRAF-mutant melanoma after long-term treatment with dabrafenib (BRAF inhibitor) and trametinib (MEK inhibitor). Triggered by this report, a systematic literature review was conducted, summarizing all other cancer cases that developed MG, after exposure to any type of targeted agent and regardless of the underlying malignancy. All available data on the clinical diagnosis, the potential of administered TKIs to induce a seropositive myasthenic syndrome, the immune and non-immune-mediated pathogenesis of postsynaptic damage, and the challenging management of this neuromuscular toxicity were collected and discussed. In the presented case, MG was confirmed by both autoantibodies and nerve-conduction tests, while its reactivation after TKIs rechallenge supports a more than coincidental association. The following review identified 12 cancer cases with TKI-related MG in six case reports and one case series. In most of them, the myasthenia diagnosis was challenging, since the clinical symptomatology of fatigable weakness was not corroborating with consistent laboratory and electrophysiological findings. In fact, anti-AchR titers were positive in five and anti-MuSK only in the abovementioned individual. The symptomatology corresponded to TKI discontinuation and standard treatment with pyridostigmine and prednisolone; intravenous immunoglobulin was added only in three, and two required mechanical ventilation. In an era where TKIs will be prescribed more frequently for various malignancies, even in combinations with immune-checkpoint inhibitors, this report synthesizes their risk for neuromuscular complications and increases the clinicians’ awareness in order to extend the on-treatment and overall survival of TKI-treated cancer patients.
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Affiliation(s)
- Dimitrios C Ziogas
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens, Greece
| | | | - Charalampos Theocharopoulos
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens, Greece
| | - Panagiotis-Petros Lialios
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens, Greece
| | - Spyros Bouros
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens, Greece
| | - Paolo A Ascierto
- Department of Melanoma, Cancer Immunotherapy and Development Therapeutics, Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
| | - Helen Gogas
- First Department of Medicine, National and Kapodistrian University of Athens, School of Medicine, Laiko General Hospital, Athens, Greece
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Myasthenia Gravis: Epidemiology, Pathophysiology and Clinical Manifestations. J Clin Med 2021; 10:jcm10112235. [PMID: 34064035 PMCID: PMC8196750 DOI: 10.3390/jcm10112235] [Citation(s) in RCA: 124] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/17/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neurological disorder characterized by defective transmission at the neuromuscular junction. The incidence of the disease is 4.1 to 30 cases per million person-years, and the prevalence rate ranges from 150 to 200 cases per million. MG is considered a classic example of antibody-mediated autoimmune disease. Most patients with MG have autoantibodies against the acetylcholine receptors (AChRs). Less commonly identified autoantibodies include those targeted to muscle-specific kinase (MuSK), low-density lipoprotein receptor-related protein 4 (Lrp4), and agrin. These autoantibodies disrupt cholinergic transmission between nerve terminals and muscle fibers by causing downregulation, destruction, functional blocking of AChRs, or disrupting the clustering of AChRs in the postsynaptic membrane. The core clinical manifestation of MG is fatigable muscle weakness, which may affect ocular, bulbar, respiratory and limb muscles. Clinical manifestations vary according to the type of autoantibody, and whether a thymoma is present.
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Sheikh S, Alvi U, Soliven B, Rezania K. Drugs That Induce or Cause Deterioration of Myasthenia Gravis: An Update. J Clin Med 2021; 10:jcm10071537. [PMID: 33917535 PMCID: PMC8038781 DOI: 10.3390/jcm10071537] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 12/20/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neuromuscular disorder which is characterized by presence of antibodies against acetylcholine receptors (AChRs) or other proteins of the postsynaptic membrane resulting in damage to postsynaptic membrane, decreased number of AChRs or blocking of the receptors by autoantibodies. A number of drugs such as immune checkpoint inhibitors, penicillamine, tyrosine kinase inhibitors and interferons may induce de novo MG by altering the immune homeostasis mechanisms which prevent emergence of autoimmune diseases such as MG. Other drugs, especially certain antibiotics, antiarrhythmics, anesthetics and neuromuscular blockers, have deleterious effects on neuromuscular transmission, resulting in increased weakness in MG or MG-like symptoms in patients who do not have MG, with the latter usually being under medical circumstances such as kidney failure. This review summarizes the drugs which can cause de novo MG, MG exacerbation or MG-like symptoms in nonmyasthenic patients.
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AChRAb and MuSKAb double-seropositive myasthenia gravis: a distinct subtype? Neurol Sci 2021; 42:863-869. [PMID: 33438140 PMCID: PMC7870615 DOI: 10.1007/s10072-021-05042-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/04/2021] [Indexed: 11/07/2022]
Abstract
Introduction This study investigated the characteristics of double-seropositive myasthenia gravis (DSP-MG) in southern China for disease subtype classification. Methods A case-control study was carried out in which the characteristics of DSP-MG patients (n = 17) were compared to those of muscle-specific tyrosine kinase antibody-positive (MuSK)-MG and acetylcholine receptor antibody-positive (AChR)-MG patients (n = 8 and 27, respectively). We also performed a literature review of DSP-MG patients. Results Compared to AChR-MG, DSP-MG had greater bulbar dysfunction (47.1% vs 18.6%, P = 0.04), higher incidence of myasthenia crisis (41.2% vs 14.8%, P = 0.04), more severe Myasthenia Gravis Foundation of America classification at maximum worsening, greater autoantibody abnormalities (70.6% vs 33.3%, P = 0.015), greater need for immunosuppressant treatment (58.8% vs 3.7%, P < 0.001), and worse prognosis with less remission (11.8% vs 55.6%, P = 0.001). There were no differences between DSP-MG and MuSK-MG patients. DSP-MG described in published reports was comparable to MuSK-MG. Discussion DSP-MG in southern China may be a subtype of MuSK-MG.
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Eker A, Tınazlı M, Mut SE. Coexistence of anti-MuSK antibody-positive myasthenia gravis and rheumatoid arthritis. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00222-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Rheumatoid arthritis (RA) is an autoimmune disease characterized with symmetric synovitis and occasional extra articular involvement; also, some neurologic disorders can be observed during the disease course. Myasthenia gravis (MG) is one of them and it is an autoimmune disease of neuromuscular junction. It is caused by autoantibodies against neuromuscular junction proteins: the nicotinic acetylcholine receptor (AChR) and the muscle specific tyrosine kinase (MuSK). Very few studies have reported the associated autoimmune disorders in MuSK-MG. Here, we present the first patient who has MuSK antibody-positive MG gravis and rheumatoid arthritis.
Case presentation
A 53-year-old woman with RA presented with fatigue and fluctuating proximal muscle weakness. Her electroneurophysiological investigation resembled MG. Her AchR antibody level was normal but MuSK antibodies were high. After the acute treatment with plasmapheresis which lead to complete recovery in myasthenic symptoms, she is following with mycophenolate mofetil.
Conclusions
Concomitant autoimmune disorders are common in the population. MG should be considered in patients with an autoimmune disorder and developing new neuromuscular weakness.
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Zhu M, Lennon VA. Double seropositivity for AChR and MuSK autoantibodies in myasthenia gravis. Neuromuscul Disord 2020; 30:533. [DOI: 10.1016/j.nmd.2020.04.003] [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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16
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Poursadeghfard M, Azhdari S. Simultaneous Presence of Acetylcholine Receptor and Muscle Specific Tyrosine Kinase Antibodies in Myasthenia Gravis. INTERNATIONAL JOURNAL OF BASIC SCIENCE IN MEDICINE 2019. [DOI: 10.34172/ijbsm.2019.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Myasthenia gravis (MG) is known as an autoimmune disorder which affects transmission in neuromuscular junction. The serologic tests used for diagnosis include acetylcholine receptor and muscle specific receptor tyrosine kinase antibodies. Studies often have reported that patients with formal antibody are negative for the latter one. However, very limited studies have reported positive anti-muscle specific receptor tyrosine kinase antibody in a small percentage of patients with acetylcholine receptor antibody. Here, we reported a young woman who was diagnosed with MG and had a rapid and progressive course of the disease. She was seropositive for both acetylcholine receptor and muscle-specific receptor tyrosine kinase antibodies simultaneously. However, she discharged from the hospital with good condition after treatment.
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Affiliation(s)
- Maryam Poursadeghfard
- Clinical Neurology Research Center, Department of Neurology, Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Azhdari
- Department of Neurology, Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
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17
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Li M, Han J, Zhang Y, Lv J, Zhang J, Zhao X, Ren L, Fang H, Yang J, Zhang Y, Cui X, Zhang Q, Li Q, Du Y, Gao F. Clinical analysis of Chinese anti-low-density-lipoprotein-receptor-associated protein 4 antibodies in patients with myasthenia gravis. Eur J Neurol 2019; 26:1296-e84. [PMID: 31050101 DOI: 10.1111/ene.13979] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/23/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE Low-density-lipoprotein-receptor-associated protein 4 (LRP4) autoantibodies have recently been detected in myasthenia gravis (MG), but little is known about the clinical characteristics associated with this serological type. In this study, the clinical features of Chinese patients with anti-LRP4 antibody-positive MG were characterized. METHODS A total of 2172 MG serum samples were collected from patients in various parts of China. An enzyme-linked immunosorbent assay was used to detect acetylcholine receptor (AChR) antibody and titin antibody, and cell-based assays were used to detect muscle-specific kinase antibody and LRP4 antibody. Clinical data for patients with MG were collected from different provinces in China. RESULTS In total, 16 (0.8%) patients with LRP4-MG were found amongst 2172 total patients, including three patients with AChR/LRP4-MG. Additionally, 13 (2.9%) patients with LRP4-MG were found amongst 455 patients with double seronegative MG. The ratio of males to females for these 13 patients was 1:1.6, and 53.8% patients were children. A total of 91.7% of cases exhibited initial ocular involvement, and 58.3% of cases exhibited simple eye muscle involvement. Responses to acetylcholinesterase inhibitors and prednisone were observed. CONCLUSION The expanded sample confirmed that the positive rate of LRP4 antibodies in China is lower than that in western countries. Our results highlighted the differences between LRP4-MG and other antibody groups. Children and female patients with LRP4-MG have a higher prevalence, often involving the ocular muscles and limb muscles. The clinical symptoms are mild, and satisfactory responses to treatment are often achieved.
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Affiliation(s)
- M Li
- Department of Neurology, Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - J Han
- Department of Neuroimmunology, Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Y Zhang
- Department of Neuroimmunology, Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - J Lv
- Department of Neuroimmunology, Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - J Zhang
- Department of Neuroimmunology, Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - X Zhao
- Department of Neuroimmunology, Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - L Ren
- Department of Neurology, Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - H Fang
- Department of Neuroimmunology, Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - J Yang
- Department of Encephalopathy, First Affiliated Hospital of Henan University of TCM, Zhengzhou, China
| | - Y Zhang
- Department of Encephalopathy, First Affiliated Hospital of Henan University of TCM, Zhengzhou, China
| | - X Cui
- Myasthenia Gravis Comprehensive Diagnosis and Treatment Center, Henan Provincial People's Hospital, Zhengzhou, China
| | - Q Zhang
- Myasthenia Gravis Comprehensive Diagnosis and Treatment Center, Henan Provincial People's Hospital, Zhengzhou, China
| | - Q Li
- Department of Immunology and Microbiology, Basic Medical College, Zhengzhou University, Zhengzhou, China
| | - Y Du
- Department of Immunology and Microbiology, Basic Medical College, Zhengzhou University, Zhengzhou, China
| | - F Gao
- Department of Neuroimmunology, Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
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Abstract
Myasthenia gravis (MG) is an autoimmune disease caused by antibodies against the acetylcholine receptor (AChR), muscle-specific kinase (MuSK) or other AChR-related proteins in the postsynaptic muscle membrane. Localized or general muscle weakness is the predominant symptom and is induced by the antibodies. Patients are grouped according to the presence of antibodies, symptoms, age at onset and thymus pathology. Diagnosis is straightforward in most patients with typical symptoms and a positive antibody test, although a detailed clinical and neurophysiological examination is important in antibody-negative patients. MG therapy should be ambitious and aim for clinical remission or only mild symptoms with near-normal function and quality of life. Treatment should be based on MG subgroup and includes symptomatic treatment using acetylcholinesterase inhibitors, thymectomy and immunotherapy. Intravenous immunoglobulin and plasma exchange are fast-acting treatments used for disease exacerbations, and intensive care is necessary during exacerbations with respiratory failure. Comorbidity is frequent, particularly in elderly patients. Active physical training should be encouraged.
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19
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Bokoliya SC, Kumar VP, Nashi S, Polavarapu K, Nalini A, Patil SA. Anti-AChR, MuSK, and LRP4 antibodies coexistence: A rare and distinct subtype of myasthenia gravis from Indian subcontinent. Clin Chim Acta 2018; 486:34-35. [DOI: 10.1016/j.cca.2018.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 05/14/2018] [Accepted: 07/09/2018] [Indexed: 11/16/2022]
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20
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Li M, Ren L, Zhang Y, Lv J, Fang H, Zhang J, Zhao X, Han J, Huang P, Du Y, Zhang Q, Yang J, Zhang Y, Gao F. Clinical characteristics of AChRAb and MuSKAb double seropositive myasthenia gravis patients. Clin Neurol Neurosurg 2018; 172:69-73. [DOI: 10.1016/j.clineuro.2018.06.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 05/22/2018] [Accepted: 06/30/2018] [Indexed: 01/02/2023]
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21
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Desai A, Sriwastava S, Gadgeel SM, Lisak RP. New onset myasthenia gravis in a patient with non small cell lung cancer treated with lorlatinib a novel anti-cancer agent. J Neurol Sci 2018; 392:100-101. [PMID: 30031992 DOI: 10.1016/j.jns.2018.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Aaron Desai
- Department of Neurology, Wayne State University/Detroit Medical Center, United States.
| | - Shitiz Sriwastava
- Department of Neurology, Wayne State University/Detroit Medical Center, United States
| | - Shirish M Gadgeel
- Karmanos Cancer Institute, Department of Oncology, Wayne State University, United States
| | - Robert P Lisak
- Department of Neurology, Wayne State University/Detroit Medical Center, United States; Department of Microbiology, Immunology and Biochemistry, Wayne State University, United States
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22
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Morren J, Li Y. Myasthenia gravis with muscle-specific tyrosine kinase antibodies: A narrative review. Muscle Nerve 2018; 58:344-358. [DOI: 10.1002/mus.26107] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/09/2018] [Accepted: 02/18/2018] [Indexed: 12/14/2022]
Affiliation(s)
- John Morren
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk S90; Cleveland Ohio 44195 USA
| | - Yuebing Li
- Neuromuscular Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk S90; Cleveland Ohio 44195 USA
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23
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Tanovska N, Novotni G, Sazdova-Burneska S, Kuzmanovski I, Boshkovski B, Kondov G, Jovanovski-Srceva M, Kokareva A, Isjanovska R. Myasthenia Gravis and Associated Diseases. Open Access Maced J Med Sci 2018; 6:472-478. [PMID: 29610603 PMCID: PMC5874368 DOI: 10.3889/oamjms.2018.110] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/03/2018] [Accepted: 02/04/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND: Myasthenia gravis (MG) is an autoimmune disease caused by the action of specific antibodies to the postsynaptic membrane of the neuromuscular junction, leading to impaired neuromuscular transmission. Patients with MG have an increased incidence of other autoimmune diseases. AIM: to determine the presence of other associated diseases in patients with MG. METHOD: A group of 127 patients with MG followed in 10 years period, in which the presence of other associated diseases has been analysed. RESULTS: The sex ratio is in favour of the female sex, the average age of the initial manifestation of the disease is less than 50 years, 65.4% of the patients with MG have another disease. 15.0% patients have associated another autoimmune disease. Thyroid disease is the most common associated with MG, rarely rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and other autoimmune diseases. Other diseases include hypertension, heart disease, diabetes, respiratory diseases, dyslipidemia. 10.2% of the patients are diagnosed with extrathymic tumours of various origins. CONCLUSION: Associated diseases are common in patients with MG, drawing attention to the possible common basis for their coexistence, as well as their impact on the intensity and treatment of the disease.
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Affiliation(s)
- Nikolina Tanovska
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Gabriela Novotni
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Slobodanka Sazdova-Burneska
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Igor Kuzmanovski
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Bojan Boshkovski
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Goran Kondov
- University Clinic for Thoracic and Vascular Surgery, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Marija Jovanovski-Srceva
- University Clinic for Anesthesia and Reanimation, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Anita Kokareva
- University Clinic for Anesthesia and Reanimation, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Rozalinda Isjanovska
- Institute for Epidemiology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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Weis CA, Schalke B, Ströbel P, Marx A. Challenging the current model of early-onset myasthenia gravis pathogenesis in the light of the MGTX trial and histological heterogeneity of thymectomy specimens. Ann N Y Acad Sci 2018; 1413:82-91. [DOI: 10.1111/nyas.13563] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 10/23/2017] [Accepted: 10/26/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Cleo-Aron Weis
- Institute of Pathology, University Medical Centre Mannheim; University of Heidelberg; Mannheim Germany
| | - Berthold Schalke
- Department of Neurology, University Hospital Regensburg; University of Regensburg; Regensburg Germany
| | - Philipp Ströbel
- Institute of Pathology, University Medical Center Göttingen; University of Göttingen; Göttingen Germany
| | - Alexander Marx
- Institute of Pathology, University Medical Centre Mannheim; University of Heidelberg; Mannheim Germany
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Horiuchi K, Nagai A, Wakita M, Ito S, Takamura K, Houzen H. Myasthenic Crisis Complicated with Myxedema, Positive for Both Anti-acetylcholine Receptor and Anti-muscle-specific Tyrosine Kinase Antibodies. Intern Med 2018; 57:265-268. [PMID: 29093409 PMCID: PMC5820048 DOI: 10.2169/internalmedicine.9291-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We herein report the case of myasthenic crisis occurring in a 51-year-old man. He had experienced ptosis, increased body weight with edema, and fatigue with dyspnea. He presented at our emergency department with disturbed consciousness. He was originally diagnosed with myxedema coma, and he required artificial respiration. Because his weakness persisted and he was positive for anti-acetylcholine receptor antibodies and anti-muscle-specific tyrosine kinase antibodies, we diagnosed myasthenic crisis after various examinations. His clinical response to treatment was good and he was discharged in an ambulatory status 3 months after admission. This case demonstrates that myasthenic crisis may occur in association with myxedema.
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Affiliation(s)
| | - Azusa Nagai
- Department of Neurology, Obihiro Kosei General Hospital, Japan
| | - Masahiro Wakita
- Department of Neurology, Obihiro Kosei General Hospital, Japan
| | - Shotaro Ito
- First Department of Medicine, Obihiro Kosei General Hospital, Japan
| | - Kei Takamura
- First Department of Medicine, Obihiro Kosei General Hospital, Japan
| | - Hideki Houzen
- Department of Neurology, Obihiro Kosei General Hospital, Japan
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Takizawa T, Kojima M, Suzuki S, Osada T, Kitagawa S, Nakahara J, Takahashi S, Suzuki N. New onset of myasthenia gravis after intravesical Bacillus Calmette-Guerin: A case report and literature review. Medicine (Baltimore) 2017; 96:e8757. [PMID: 29145329 PMCID: PMC5704874 DOI: 10.1097/md.0000000000008757] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
RATIONALE Recently, drug-related myasthenia gravis (MG) has received attention, because the number of reported cases involving MG associated with immune checkpoint inhibitors, a new immunotherapy, is increasing. We present a case involving the new onset of MG, in which the symptoms started shortly after intravesical Bacillus Calmette-Guerin (BCG) for bladder cancer. PATIENT CONCERNS A 69-year-old male with bladder cancer developed ptosis and diplopia 4 days after the completion of a treatment regimen with intravesical BCG weekly for 6 weeks. DIAGNOSES Ocular MG was confirmed by a positive serum anti-acetylcholine receptor antibody test. INTERVENTIONS Treatment with high-dose methylprednisolone pulse therapy was given, after insufficient treatment with pyridostigmine bromide and 10 mg/d prednisolone. OUTCOMES Symptoms resolved completely 12 days after high-dose methylprednisolone pulse therapy. LESSONS Intravesical BCG could be listed as a novel drug that may induce a new onset of MG along with drugs such as D-penicillamine and immune checkpoint inhibitors.
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28
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Switch to double positive late onset MuSK myasthenia gravis following thymomectomy in paraneoplastic AChR antibody positive myasthenia gravis. J Neurol 2015; 263:174-6. [DOI: 10.1007/s00415-015-7982-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 11/10/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
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MuSK autoantibodies in myasthenia gravis detected by cell based assay--A multinational study. J Neuroimmunol 2015; 284:10-7. [PMID: 26025053 DOI: 10.1016/j.jneuroim.2015.04.015] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 04/21/2015] [Accepted: 04/24/2015] [Indexed: 12/21/2022]
Abstract
Seronegative myasthenia gravis (MG) presents a serious gap in MG diagnosis and understanding. We applied a cell based assay (CBA) for the detection of muscle specific kinase (MuSK) antibodies undetectable by radioimmunoassay. We tested 633 triple-seronegative MG patients' sera from 13 countries, detecting 13% as positive. MuSK antibodies were found, at significantly lower frequencies, in 1.9% of healthy controls and 5.1% of other neuroimmune disease patients, including multiple sclerosis and neuromyelitis optica. The clinical data of the newly diagnosed MuSK-MG patients are presented. 27% of ocular seronegative patients were MuSK antibody positive. Moreover, 23% had thymic hyperplasia suggesting that thymic abnormalities are more common than believed.
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Nacu A, Andersen JB, Lisnic V, Owe JF, Gilhus NE. Complicating autoimmune diseases in myasthenia gravis: a review. Autoimmunity 2015; 48:362-8. [PMID: 25915571 PMCID: PMC4616023 DOI: 10.3109/08916934.2015.1030614] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Myasthenia gravis (MG) is a rare autoimmune disease of skeletal muscle endplates. MG subgroup is relevant for comorbidity, but usually not accounted for. MG patients have an increased risk for complicating autoimmune diseases, most commonly autoimmune thyroid disease, systemic lupus erythematosus and rheumatoid arthritis. In this review, we present concomitant autoimmune disorders associated with the different MG subgroups, and show how this influences treatment and prognosis. Concomitant MG should always be considered in patients with an autoimmune disorder and developing new neuromuscular weakness, fatigue or respiratory failure. When a second autoimmune disorder is suspected, MG should be included as a differential diagnosis.
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Affiliation(s)
- Aliona Nacu
- a Department of Neurology , Haukeland University Hospital , Bergen , Norway
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Berrih-Aknin S. Myasthenia Gravis: paradox versus paradigm in autoimmunity. J Autoimmun 2014; 52:1-28. [PMID: 24934596 DOI: 10.1016/j.jaut.2014.05.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 05/07/2014] [Indexed: 12/12/2022]
Abstract
Myasthenia Gravis (MG) is a paradigm of organ-specific autoimmune disease (AID). It is mediated by antibodies that target the neuromuscular junction. The purpose of this review is to place MG in the general context of autoimmunity, to summarize the common mechanisms between MG and other AIDs, and to describe the specific mechanisms of MG. We have chosen the most common organ-specific AIDs to compare with MG: type 1 diabetes mellitus (T1DM), autoimmune thyroid diseases (AITD), multiple sclerosis (MS), some systemic AIDs (systemic lupus erythematous (SLE), rheumatoid arthritis (RA), Sjogren's syndrome (SS)), as well as inflammatory diseases of the gut and liver (celiac disease (CeD), Crohn's disease (CD), and primary biliary cirrhosis (PBC)). Several features are similar between all AIDs, suggesting that common pathogenic mechanisms lead to their development. In this review, we address the predisposing factors (genetic, epigenetic, hormones, vitamin D, microbiota), the triggering components (infections, drugs) and their interactions with the immune system [1,2]. The dysregulation of the immune system is detailed and includes the role of B cells, Treg cells, Th17 and cytokines. We particularly focused on the role of TNF-α and interferon type I whose role in MG is very analogous to that in several other AIDS. The implication of AIRE, a key factor in central tolerance is also discussed. Finally, if MG is a prototype of AIDS, it has a clear specificity compared to the other AIDS, by the fact that the target organ, the muscle, is not the site of immune infiltration and B cell expansion, but exclusively that of antibody-mediated pathogenic mechanisms. By contrast, the thymus in the early onset subtype frequently undergoes tissue remodeling, resulting in the development of ectopic germinal centers surrounded by high endothelial venules (HEV), as observed in the target organs of many other AIDs.
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Affiliation(s)
- Sonia Berrih-Aknin
- Sorbonne Universités, UPMC Univ Paris 06, Myology Research Center UM76, F-75013 Paris, France; INSERM U974, F-75013 Paris, France; CNRS FRE 3617, F-75013 Paris, France; Institute of Myology, F-75013 Paris, France.
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Sieb JP. Myasthenia gravis: an update for the clinician. Clin Exp Immunol 2014; 175:408-18. [PMID: 24117026 DOI: 10.1111/cei.12217] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2013] [Indexed: 01/16/2023] Open
Abstract
This paper provides a thorough overview of the current advances in diagnosis and therapy of myasthenia gravis (MG). Nowadays the term 'myasthenia gravis' includes heterogeneous autoimmune diseases, with a postsynaptic defect of neuromuscular transmission as the common feature. Myasthenia gravis should be classified according to the antibody specificity [acetylcholine, muscle-specific receptor tyrosine kinase (MuSK), low-density lipoprotein receptor-related protein 4 (LRP4), seronegative], thymus histology (thymitis, thymoma, atrophy), age at onset (in children; aged less than or more than 50 years) and type of course (ocular or generalized). With optimal treatment, the prognosis is good in terms of daily functions, quality of life and survival. Symptomatic treatment with acetylcholine esterase inhibition is usually combined with immunosuppression. Azathioprine still remains the first choice for long-term immunosuppressive therapy. Alternative immunosuppressive options to azathioprine include cyclosporin, cyclophosphamide, methotrexate, mycophenolate mofetil and tacrolimus. Rituximab is a promising new drug for severe generalized MG. Emerging therapy options include belimumab, eculizumab and the granulocyte- macrophage colony-stimulating factor. One pilot study on etanercept has given disappointing results. For decades, thymectomy has been performed in younger adults to improve non-paraneoplastic MG. However, controlled prospective studies on the suspected benefit of this surgical procedure are still lacking. In acute exacerbations, including myasthenic crisis, intravenous immunoglobulin, plasmapheresis and immunoadsorption are similarly effective.
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Affiliation(s)
- J P Sieb
- Department of Neurology, HELIOS Hanseklinikum Stralsund, University Hospital Bonn, Germany
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Zouvelou V, Zisimopoulou P, Psimenou E, Matsigkou E, Stamboulis E, Tzartos SJ. AChR-myasthenia gravis switching to double-seropositive several years after the onset. J Neuroimmunol 2014; 267:111-2. [DOI: 10.1016/j.jneuroim.2013.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 12/08/2013] [Accepted: 12/17/2013] [Indexed: 11/16/2022]
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Zisimopoulou P, Evangelakou P, Tzartos J, Lazaridis K, Zouvelou V, Mantegazza R, Antozzi C, Andreetta F, Evoli A, Deymeer F, Saruhan-Direskeneli G, Durmus H, Brenner T, Vaknin A, Berrih-Aknin S, Frenkian Cuvelier M, Stojkovic T, DeBaets M, Losen M, Martinez-Martinez P, Kleopa KA, Zamba-Papanicolaou E, Kyriakides T, Kostera-Pruszczyk A, Szczudlik P, Szyluk B, Lavrnic D, Basta I, Peric S, Tallaksen C, Maniaol A, Tzartos SJ. A comprehensive analysis of the epidemiology and clinical characteristics of anti-LRP4 in myasthenia gravis. J Autoimmun 2013; 52:139-45. [PMID: 24373505 DOI: 10.1016/j.jaut.2013.12.004] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 12/08/2013] [Indexed: 11/29/2022]
Abstract
Double-seronegative myasthenia gravis (dSN-MG, without detectable AChR and MuSK antibodies) presents a serious gap in MG diagnosis and understanding. Recently, autoantibodies against the low-density lipoprotein receptor-related protein 4 (LRP4) have been identified in several dSN-MG sera, but with dramatic frequency variation (∼2-50%). We have developed a cell based assay (CBA) based on human LRP4 expressing HEK293 cells, for the reliable and efficient detection of LRP4 antibodies. We have screened about 800 MG patient sera from 10 countries for LRP4 antibodies. The overall frequency of LRP4-MG in the dSN-MG group (635 patients) was 18.7% but with variations among different populations (range 7-32.7%). Interestingly, we also identified double positive sera: 8/107 anti-AChR positive and 10/67 anti-MuSK positive sera also had detectable LRP4 antibodies, predominantly originating from only two of the participating groups. No LRP4 antibodies were identified in sera from 56 healthy controls tested, while 4/110 from patients with other neuroimmune diseases were positive. The clinical data, when available, for the LRP4-MG patients were then studied. At disease onset symptoms were mild (81% had MGFA grade I or II), with some identified thymic changes (32% hyperplasia, none with thymoma). On the other hand, double positive patients (AChR/LRP4-MG and MuSK/LRP4-MG) had more severe symptoms at onset compared with any single positive MG subgroup. Contrary to MuSK-MG, 27% of ocular dSN-MG patients were LRP4 antibody positive. Similarly, contrary to MuSK antibodies, which are predominantly of the IgG4 subtype, LRP4 antibodies were predominantly of the IgG1 and IgG2 subtypes. The prevalence was higher in women than in men (female/male ratio 2.5/1), with an average disease onset at ages 33.4 for females and 41.9 for males. Overall, the response of LRP4-MG patients to treatment was similar to published responses of AChR-MG rather than to MuSK-MG patients.
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Affiliation(s)
| | - P Evangelakou
- Hellenic Pasteur Institute, Athens, Greece; University of Patras, Patras, Greece
| | - J Tzartos
- Hellenic Pasteur Institute, Athens, Greece
| | | | - V Zouvelou
- Neurology Department, Aeginition Hospital, Athens, Greece
| | - R Mantegazza
- Neurological Institute "C. Besta", Milano, Italy
| | - C Antozzi
- Neurological Institute "C. Besta", Milano, Italy
| | - F Andreetta
- Neurological Institute "C. Besta", Milano, Italy
| | - A Evoli
- Institute of Neurology, Catholic University, Rome, Italy
| | - F Deymeer
- Istanbul University, Istanbul, Turkey
| | | | - H Durmus
- Istanbul University, Istanbul, Turkey
| | - T Brenner
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - A Vaknin
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | | | | | - M DeBaets
- School for Mental Health and Neuroscience, Maastricht University, The Netherlands
| | - M Losen
- School for Mental Health and Neuroscience, Maastricht University, The Netherlands
| | - P Martinez-Martinez
- School for Mental Health and Neuroscience, Maastricht University, The Netherlands
| | - K A Kleopa
- The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | | | - T Kyriakides
- The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | | | - P Szczudlik
- Department of Neurology, Medical University of Warsaw, Poland
| | - B Szyluk
- Department of Neurology, Medical University of Warsaw, Poland
| | - D Lavrnic
- Serbia, Clinic of Neurology, Clinical Center of Serbia, Serbia
| | - I Basta
- Serbia, Clinic of Neurology, Clinical Center of Serbia, Serbia
| | - S Peric
- Serbia, Clinic of Neurology, Clinical Center of Serbia, Serbia
| | - C Tallaksen
- Norway Department of Neurology, Ullevaal University Hospital, Oslo, Norway
| | - A Maniaol
- Norway Department of Neurology, Ullevaal University Hospital, Oslo, Norway
| | - S J Tzartos
- Hellenic Pasteur Institute, Athens, Greece; University of Patras, Patras, Greece.
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Pula JH, Kao AM, Kattah JC. Neuro-ophthalmologic side-effects of systemic medications. Curr Opin Ophthalmol 2013; 24:540-9. [DOI: 10.1097/01.icu.0000434557.30065.a7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Eymard B. [Myasthenia, from the internist's point of view]. Rev Med Interne 2013; 35:421-9. [PMID: 24112993 DOI: 10.1016/j.revmed.2013.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 08/21/2013] [Indexed: 01/02/2023]
Abstract
Myasthenia gravis is an autoimmune disease due to specific antibodies inducing a neuromuscular transmission defect causing muscle fatigability. If onset of the disease may be at any age, myasthenia gravis concerns mostly young adults, in majority females. The disease characteristic features are the following: ocular symptoms (ptosis or diplopia) as main initial manifestation, extension to other muscles in 80 % of the cases, variability of the deficit, effort induced worsening, successive periods of exacerbation during the disease course, severity depending on respiratory and swallowing impairment (if rapid worsening, a myasthenic crisis is to be suspected), association with thymoma in 20 % of patients and with other various autoimmune diseases, most commonly hyperthyroidism and Hashimoto's disease. Diagnosis relies on the clinical features, improvement with cholinesterase inhibitors, detection of specific autoantibodies (anti-AChR or anti-MuSK), and significant decrement evidenced by electrophysiological tests. The points concerning specifically the internist have been highlighted in this article: diagnostic traps, associated autoimmune diseases, including inflammatory myopathies that may mimic myasthenia gravis, adverse effects of medications commonly used in internal medicine, some of them inducing myasthenic syndromes. The treatment is well codified: the treatment is well codified: (1) respect of adverse drugs contra-indications, systematically use of cholinesterase inhibitors, (2) thymectomy if thymoma completed with radiotherapy if malignant, (3) corticosteroids or immunosuppressive agent in severe or disabling form, (4) intensive care unit monitoring, plasmapheresis or intravenous immunoglobulins for patients with myasthenic crisis.
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Affiliation(s)
- B Eymard
- Unité de pathologie neuromusculaire, service de neurologie 2, centre de référence de pathologie neuromusculaire Paris Est, hôpital de la Pitié-Salpêtrière, institut de myologie, bâtiment Babinski, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France. anne-marie.maronne.@psl.aphp.fr
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Cavalcante P, Cufi P, Mantegazza R, Berrih-Aknin S, Bernasconi P, Le Panse R. Etiology of myasthenia gravis: Innate immunity signature in pathological thymus. Autoimmun Rev 2013; 12:863-74. [DOI: 10.1016/j.autrev.2013.03.010] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2013] [Indexed: 01/09/2023]
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Somashekar DK, Davenport MS, Cohan RH, Dillman JR, Ellis JH. Effect of Intravenous Low-Osmolality Iodinated Contrast Media on Patients with Myasthenia Gravis. Radiology 2013; 267:727-34. [DOI: 10.1148/radiol.12121508] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ishak R, Abbas O. Penicillamine revisited: historic overview and review of the clinical uses and cutaneous adverse effects. Am J Clin Dermatol 2013; 14:223-33. [PMID: 23605177 DOI: 10.1007/s40257-013-0022-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Penicillamine is a well-known heavy metal chelator, classically used in the treatment of Wilson disease, rheumatoid arthritis, and cystinuria. From a dermatologic standpoint, penicillamine was found to be useful in the treatment of systemic sclerosis. The successful therapeutic uses of penicillamine have been hindered by its numerous adverse effects, both cutaneous and extra-cutaneous. It is a unique drug since it provokes a diversity of dermatologic manifestations that include (1) acute hypersensitivity reactions, (2) dermopathies characterized by elastic fiber abnormalities including elastosis perforans serpiginosa and pseudo-pseudoxanthoma elasticum, (3) autoimmune disorders such as pemphigus and penicillamine-induced lupus erythematosus-like syndrome, and (4) miscellaneous dermatoses that result from undefined mechanisms. These cutaneous adverse effects may correlate with the dosage and duration of penicillamine therapy as well as the disease being treated.
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Affiliation(s)
- Rim Ishak
- Department of Dermatology, American University of Beirut Medical Center, Riad El Solh/Beirut, P.O. Box 11-0236, Beirut 1107 2020, Lebanon
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Zouvelou V, Kyriazi S, Rentzos M, Belimezi M, Micheli MA, Tzartos SJ, Stamboulis E. Double-seropositive myasthenia gravis. Muscle Nerve 2013; 47:465-6. [DOI: 10.1002/mus.23645] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 08/19/2012] [Accepted: 08/21/2012] [Indexed: 11/07/2022]
Affiliation(s)
- Vasiliki Zouvelou
- Neurology Department; Aeginition Hospital; University of Athens; Athens; Greece
| | - Stavroula Kyriazi
- MRI Department; Evgenideion Hospital; University of Athens; Athens; Greece
| | - Michael Rentzos
- Neurology Department; Aeginition Hospital; University of Athens; Athens; Greece
| | - Maria Belimezi
- Department of Biochemistry; Hellenic Pasteur Institute; Athens; Greece
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