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Zhu M, Wang Y, Xu X, Guo X, Mao Y, Gao F. Small extracellular vesicle microRNAs in pediatric myasthenia gravis plasma and skeletal muscle. Postgrad Med J 2024; 100:488-495. [PMID: 38449066 DOI: 10.1093/postmj/qgae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND The diagnosis of myasthenia gravis (MG) in children remains difficult. Circulating small extracellular vesicle (sEV)-derived miRNAs (sEV-miRNAs) have been recognized as biomarkers of various diseases and can be excreted by different cell types. These biomarker candidates also play a vital role in autoimmune diseases via intercellular communication. METHODS In the present study, we used sEV isolation and purification methods to extract the plasma-derived sEV-miRNAs from children with MG and healthy controls. A small RNA sequencing analysis confirmed the miRNA expression features in plasma-derived sEVs from MG patients. The miRNA expression analysis in vitro was determined using microarray analysis. The enrichment and network analyses of altered sEV-miRNAs were performed using miRNA databases and Database for Annotation, Visualization, and Integrated Discovery website. Quantitative real-time polymerase chain reaction was performed for validation of sEV-miRNA. The diagnostic power of altered sEV-miRNAs was evaluated using receiver operating characteristic curve analyses. RESULTS Twenty-four sEV-miRNAs with altered expression level were identified between groups by DESeq2 method. The miRNAs were extracted from the sEVs, which were isolated from human primary skeletal muscle cell culture treated with mAb198. The target genes and enriched pathways of sEV-miRNAs partially overlapped between cell supernatant and plasma samples. The significantly downregulated miR-143-3p was validated in quantitative real-time polymerase chain reaction analysis. CONCLUSIONS For the first time, we report that plasma-derived sEV-miRNAs may act as novel circulating biomarkers and therapeutic targets in pediatric MG.
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Affiliation(s)
- Mengying Zhu
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
- National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
| | - Yilong Wang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
- National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
| | - Xuebin Xu
- National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
| | - Xiaotong Guo
- National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
| | - Yuchen Mao
- National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
| | - Feng Gao
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
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2
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Maeda M, Shimomura H, Tokunaga S, Taniguchi N, Lee T, Takeshima Y. Clinical Characteristics and Treatment of Juvenile Myasthenia Gravis-A Single-Center Experience. CHILDREN (BASEL, SWITZERLAND) 2024; 11:572. [PMID: 38790567 PMCID: PMC11120409 DOI: 10.3390/children11050572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/02/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024]
Abstract
Juvenile myasthenia gravis (MG) is a rare autoimmune neuromuscular disease, often treated with anticholinesterases, corticosteroids, and immunosuppressants. However, optimal treatment durations remain unclear. This study investigated the clinical characteristics and treatment of juvenile MG, including medication duration. The administration period for all drugs, immunosuppressants, and prednisolone at doses greater than 0.35 mg/kg daily was extracted retrospectively from medical records. Nineteen participants (8 boys, 11 girls) aged 8 months to 14 years (median, 2.5 years) at onset were identified. Fourteen patients (73.7%) had ocular MG and five (26.3%) had generalized MG. Drug treatment was conducted in 18 cases; however, 7 patients did not complete the treatment. Among the patients who completed drug treatment, the duration of treatment ranged from 11 to 100 months (median, 47 months). In the six patients treated with continuous administration of prednisolone or immunosuppressants, the treatment duration ranged from 33 to 99 months (median, 56 months). No severe adverse effects requiring hospitalization were reported. The patients treated with prednisolone or immunosuppressants required at least 33 months of treatment. These results will help develop protocols for juvenile MG treatment.
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Affiliation(s)
| | - Hideki Shimomura
- Department of Pediatrics, Hyogo Medical University School of Medicine, 1-1, Mukogawa, Nishinomiya 663-8501, Japan; (M.M.); (S.T.); (N.T.); (T.L.); (Y.T.)
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3
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Godavarthi SK, Hiramoto M, Ignatyev Y, Levin JB, Li HQ, Pratelli M, Borchardt J, Czajkowski C, Borodinsky LN, Sweeney L, Cline HT, Spitzer NC. Postsynaptic receptors regulate presynaptic transmitter stability through transsynaptic bridges. Proc Natl Acad Sci U S A 2024; 121:e2318041121. [PMID: 38568976 PMCID: PMC11009644 DOI: 10.1073/pnas.2318041121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/27/2024] [Indexed: 04/05/2024] Open
Abstract
Stable matching of neurotransmitters with their receptors is fundamental to synapse function and reliable communication in neural circuits. Presynaptic neurotransmitters regulate the stabilization of postsynaptic transmitter receptors. Whether postsynaptic receptors regulate stabilization of presynaptic transmitters has received less attention. Here, we show that blockade of endogenous postsynaptic acetylcholine receptors (AChR) at the neuromuscular junction destabilizes the cholinergic phenotype in motor neurons and stabilizes an earlier, developmentally transient glutamatergic phenotype. Further, expression of exogenous postsynaptic gamma-aminobutyric acid type A receptors (GABAA receptors) in muscle cells stabilizes an earlier, developmentally transient GABAergic motor neuron phenotype. Both AChR and GABAA receptors are linked to presynaptic neurons through transsynaptic bridges. Knockdown of specific components of these transsynaptic bridges prevents stabilization of the cholinergic or GABAergic phenotypes. Bidirectional communication can enforce a match between transmitter and receptor and ensure the fidelity of synaptic transmission. Our findings suggest a potential role of dysfunctional transmitter receptors in neurological disorders that involve the loss of the presynaptic transmitter.
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Affiliation(s)
- Swetha K. Godavarthi
- Neurobiology Department, University of California San Diego, La Jolla, CA92093
- Kavli Institute for Brain & Mind, University of California San Diego, La Jolla, CA92093
| | - Masaki Hiramoto
- Neuroscience Department, The Scripps Research Institute, La Jolla, CA92037
| | - Yuri Ignatyev
- Institute of Science and Technology Austria, Klosterneuburg3400, Austria
| | - Jacqueline B. Levin
- Department of Physiology & Membrane Biology Shriners Hospital for Children Northern California, University of California Davis School of Medicine, Sacramento, CA95817
| | - Hui-quan Li
- Neurobiology Department, University of California San Diego, La Jolla, CA92093
- Kavli Institute for Brain & Mind, University of California San Diego, La Jolla, CA92093
| | - Marta Pratelli
- Neurobiology Department, University of California San Diego, La Jolla, CA92093
- Kavli Institute for Brain & Mind, University of California San Diego, La Jolla, CA92093
| | - Jennifer Borchardt
- Neuroscience Department, University of Wisconsin Madison, Madison, WI53705
| | - Cynthia Czajkowski
- Neuroscience Department, University of Wisconsin Madison, Madison, WI53705
| | - Laura N. Borodinsky
- Department of Physiology & Membrane Biology Shriners Hospital for Children Northern California, University of California Davis School of Medicine, Sacramento, CA95817
| | - Lora Sweeney
- Institute of Science and Technology Austria, Klosterneuburg3400, Austria
| | - Hollis T. Cline
- Neuroscience Department, The Scripps Research Institute, La Jolla, CA92037
| | - Nicholas C. Spitzer
- Neurobiology Department, University of California San Diego, La Jolla, CA92093
- Kavli Institute for Brain & Mind, University of California San Diego, La Jolla, CA92093
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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.
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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
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Kline M, Fuller K, Gray K. Myasthenia Gravis in Pregnancy and the Newborn. Neoreviews 2024; 25:e228-e231. [PMID: 38556492 DOI: 10.1542/neo.25-3-e228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Meagan Kline
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kisti Fuller
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kendra Gray
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
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Kline M, Fuller K, Gray K. Myasthenia Gravis in Pregnancy and the Newborn. Neoreviews 2024; 25:e228-e231. [PMID: 38556501 DOI: 10.1542/neo.25-4-e228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Meagan Kline
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kisti Fuller
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kendra Gray
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
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Yang J, Pan L, Liu Y, Wang Y. Transient Neonatal Myasthenia Gravis Born to a Mother with Asymptomatic MG: A Case Report. Degener Neurol Neuromuscul Dis 2024; 14:15-19. [PMID: 38444566 PMCID: PMC10913793 DOI: 10.2147/dnnd.s451611] [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] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/26/2024] [Indexed: 03/07/2024] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease which can impact pregnancy. We describe a transient neonatal myasthenia gravis (TNMG) born to an asymptomatic mother aged 26. The newborn presented cyanosis and generalized muscular weakness quickly after birth. Nasal continuous positive airway pressure (nCPAP) ventilation was performed immediately. On day 3, detailed family history showed that the neonate's 50-year-old maternal grandmother was diagnosed as ocular MG at the age of 40. Ryanodine receptor calcium release channel antibody (RyR-Ab) and acetylcholine receptor antibody (AChR-Ab) tested on day 5 were positive. However, neostigmine tests were negative for the neonate. Intravenous immunoglobulin (IVIG) and oral pyridostigmine were administered. The infant was weaned from the ventilator on day 7. On day 10, the neonate's asymptomatic mother was confirmed to have positive AChR-Ab either. The neonate regained the capability of bottle feeding on day 17 and discharged on day 26. Asymptomatic pregnant women with MG family history can also deliver infants who develop TNMG. Testing AChR antibodies in pregnant women with a family history of MG should be necessary as TNMG was a life-threatening disease. With timely diagnosis and accurate treatment, TNMG can be effectively relieved.
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Affiliation(s)
- Jinrong Yang
- Department of Neonatology, Shenzhen Third People’s Hospital, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, People’s Republic of China
| | - Liping Pan
- Department of Neonatology, Shenzhen Third People’s Hospital, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, People’s Republic of China
| | - Yaping Liu
- Department of Neonatology, Shenzhen Third People’s Hospital, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, People’s Republic of China
| | - Yanrong Wang
- Department of Neonatology, Shenzhen Third People’s Hospital, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, People’s Republic of China
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Özsoy Ö, Cinleti T, Günay Ç, Sarıkaya Uzan G, Giray Bozkaya Ö, Çağlayan AO, Hız Kurul S, Yiş U. Genetic, serological and clinical evaluation of childhood myasthenia syndromes- single center subgroup analysis experience in Turkey. Acta Neurol Belg 2023; 123:2325-2335. [PMID: 37656362 DOI: 10.1007/s13760-023-02370-3] [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: 04/04/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Congenital myasthenic syndrome is a disease that occurs due to several types such as mutations in different pre-synaptic, synaptic, post-synaptic proteins and, glycosylation defects associated with congenital myopathy. Juvenile myasthenia gravis is an autoimmune condition usually caused by antibodies targeting the acetylcholine receptor. AIMS Our objective is to conduct an analysis on the subgroup traits exhibited by patients who have been diagnosed with congenital myasthenic syndrome and juvenile myasthenia gravis, with a focus on their long-term monitoring and management. METHODS This study was conducted on children diagnosed with myasthenia gravis, who were under the care of Dokuz Eylul University's Department of Pediatric Neurology for a period of ten years. RESULTS A total of 22 (12 congenital myasthenic syndrome, 10 juvenile myasthenia gravis) patients were identified. Defects in the acetylcholine receptor (6/12) were the most common type in the congenital myasthenic syndrome group. Basal-lamina-related defects (5/12) were the second most prevalent. One patient had a GFPT1 gene mutation (1/12). Patients with ocular myasthenia gravis (n = 6) exhibited milder symptoms. In the generalized myasthenia gravis group (n = 4), specifically in postpubertal girls, a more severe clinical progression was observed, leading to the implementation of more aggressive treatment strategies. CONCLUSION This study highlights that clinical recognition of congenital myasthenic syndrome and knowledge of related genes will aid the rapid diagnosis and treatment of these rare neuromuscular disorders. Findings in the juvenile myasthenia gravis group demonstrate the impact of pubertal development and the need for timely and appropriate active therapy, including thymectomy, to improve prognosis.
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Affiliation(s)
- Özlem Özsoy
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey.
| | - Tayfun Cinleti
- Department of Pediatric Genetics, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Çağatay Günay
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Gamze Sarıkaya Uzan
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Özlem Giray Bozkaya
- Department of Pediatric Genetics, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Ahmet Okay Çağlayan
- Department of Medical Genetics, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
- Department of Molecular Medicine, Institute of Health Sciences, Dokuz Eylül University, İzmir, Turkey
| | - Semra Hız Kurul
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
- İzmir Biomedicine and Genome Center, Dokuz Eylül University Health Campus, İzmir, Turkey
- İzmir International Biomedicine and Genome Institute, Dokuz Eylül University, İzmir, Turkey
| | - Uluç Yiş
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
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Mukhtiar K, Raza M, Tejani I, Ali F, Ibrahim S. Diagnostic dilemmas and challenges in the management of myasthenia in infants and toddlers: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231211047. [PMID: 38022851 PMCID: PMC10631333 DOI: 10.1177/2050313x231211047] [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: 07/05/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Myasthenia in the infancy and toddler age group is rare and often presents a challenge to treating pediatric neurologists. Our report addresses the challenges encountered when distinguishing myasthenia in infants and toddlers from similar illnesses, as well as the differentiation between congenital myasthenia, transient myasthenia, and autoimmune myasthenia. We present four cases of myasthenia between the ages of 10 and 30 months. The diagnosis and management of these cases were challenging due to the variability in clinical presentation. Four cases of myasthenia were diagnosed, with three having autoimmune myasthenia and one having congenital myasthenic syndrome. One patient initially tested negative for acetylcholine receptor antibodies, but later tested positive after 4 months and had a rare facial diplegia finding. The patient with congenital myasthenic syndrome had a novel genetic mutation, DPAGT1 homozygous variants, and also had false positive acetylcholine receptor antibodies. These cases highlight the importance of genetic testing for all infants and toddlers suspected of having myasthenia.
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Affiliation(s)
- Khairunnisa Mukhtiar
- Department of Pediatrics & Child Health, Section of Pediatric Neurology, Aga Khan University Hospital, Karachi, Pakistan
| | - Mohammad Raza
- Department of Pediatrics & Child Health, Section of Pediatric Neurology, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Farhan Ali
- Department of Pediatrics & Child Health, Section of Pediatric Neurology, Aga Khan University Hospital, Karachi, Pakistan
| | - Shahnaz Ibrahim
- Department of Pediatrics & Child Health, Section of Pediatric Neurology, Aga Khan University Hospital, Karachi, Pakistan
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De Boer C, Zeineddin S, Ott K, Hu A, Linton S, George M, Rao VK, Abdullah F, Chin A, Goldstein SD. Measuring the Efficacy of Thymectomy for Pediatric Myasthenia Gravis Across Tertiary Children's Hospitals. Pediatr Neurol 2023; 148:17-22. [PMID: 37651972 DOI: 10.1016/j.pediatrneurol.2023.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/23/2023] [Accepted: 07/31/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Thymectomy is a treatment for pediatric myasthenia gravis, but the efficacy over time is unknown. Multi-institutional data are also lacking. Therefore, the objective of this study was to determine the efficacy of thymectomy for pediatric myasthenia gravis using medication burden and health care utilization as proxies for disease severity. METHODS This was a cross-sectional study of the Pediatric Health Information System database among children who underwent thymectomy at one of 49 children's hospitals from 2004 to 2022. Differences in annual median number of doses of myasthenia-related medications, admissions, and health care costs in the year before thymectomy to three years after were compared. A comparison cohort that did not undergo thymectomy was utilized. Medians were compared using the Wilcoxon signed-rank test. Generalized linear regression estimated the effect of surgical approach on outcomes. RESULTS A total of451 patients (238 patients who underwent thymectomy and 213 nonthymectomy patients) were identified. Following thymectomy, the decrease in annual median total number of myasthenia-related doses was 12.0 (interquartile range: 6 to 31) (P < 0.001). The decrease in number of annual admissions was 2.0 (1 to 4) (P < 0.001), which represented a cost difference of $5292 ($3533 to $8681) (P < 0.001). No differences were observed in the control cohort. In a generalized linear regression model, surgical approach was not associated with the efficacy of thymectomy (P = 0.55). CONCLUSIONS Thymectomy is an effective treatment for pediatric myasthenia gravis, evidenced by the decreased medication burden and health care utilization after surgery. Surgical approach did not influence the success of surgery. Thymectomy should be considered earlier in the treatment algorithm.
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Affiliation(s)
- Christopher De Boer
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Katherine Ott
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michael George
- Division of Rheumatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vamshi K Rao
- Division of Neurology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Anthony Chin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Ks A, Kumar V, Ms AR, Bhat NK. Acute liver failure due to hepatitis A virus presented with Guillain-Barré syndrome and ocular myasthenia gravis. BMJ Case Rep 2023; 16:e254855. [PMID: 37813556 PMCID: PMC10565331 DOI: 10.1136/bcr-2023-254855] [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] [Indexed: 10/13/2023] Open
Abstract
Hepatitis A is one of the most common causes of acute viral hepatitis in children. Immunological manifestations involving the nervous system are rare with hepatitis A infection. We report a case of a toddler who presented with acute liver failure secondary to hepatitis A infection. The child showed clinical and laboratory improvement initially with conservative management. However, after the initial improvement, she developed acute-onset ptosis along with areflexia. Serological and neurophysiological tests revealed the occurrence of ocular variant Guillain-Barré syndrome and ocular myasthenia gravis, which was only partially responsive to treatment (intravenous immunoglobulin and pyridostigmine). A sudden clinical deterioration was noted after the onset of ptosis. She succumbed on day 40 of hospitalisation due to hospital-acquired infection along with the primary hepatic pathology. This is a rare coincidental presentation of acute viral hepatitis A infection with autoimmune manifestations.
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Affiliation(s)
- Aswanth Ks
- Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Vinod Kumar
- Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Akhil Raj Ms
- Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Nowneet Kumar Bhat
- Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Ristovska S, Stomnaroska O, Dimitrioska R. Transient Neonatal Myasthenia Gravis: A Case Report. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2023; 44:165-169. [PMID: 37453109 DOI: 10.2478/prilozi-2023-0036] [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] [Indexed: 07/18/2023]
Abstract
Transient neonatal myasthenia gravis (TNMG) is a neuromuscular disorder that occurs in infants born from mothers with myasthenia gravis (MG) due to transplacental transfer of antibodies against the acetylcholine receptor. TNMG is a rare form occurring in 10-15% of infants born from mothers with MG. We present a case of a newborn with TNMG with generalized hypotonia and respiratory distress. The newborn shows symptoms of hypotonia, weakened reflexes, poor crying, difficult sucking and potentiated tachydyspnea after 24 hours of birth and needs of assisted mechanical ventilation. Based on the mother's positive history of MG and the high titer of mother's (8.43nmol/l) and newborn's (9.088nmol/l) anti-AChR antibodies, TNMG was diagnosed. The baby was treated with assisted mechanical ventilation and neostig-mine until the anti-AChR antibody titer was negative. Adequate management of the newborn resulted in a positive outcome and evident withdrawal of the symptoms. Although TNMG is one of the rare neuromuscular disorders in newborns that can be treated, a multidisciplinary approach in the management of pregnant women with MG and newborns through timely diagnosis and early appropriate treatment, results in successful resolution of this condition.
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Affiliation(s)
- Sanja Ristovska
- 1PJU University Clinic for Gynecology and Obstetrics, Faculty of Medicine, University "St. Cyril and Methodius", Skopje
| | - Orhideja Stomnaroska
- 1PJU University Clinic for Gynecology and Obstetrics, Faculty of Medicine, University "St. Cyril and Methodius", Skopje
| | - Renata Dimitrioska
- 1PJU University Clinic for Gynecology and Obstetrics, Faculty of Medicine, University "St. Cyril and Methodius", Skopje
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Arruti N, Munot P, Bowman R. Demographics and ocular findings in children with myasthenia. Eye (Lond) 2023; 37:700-704. [PMID: 35338356 PMCID: PMC9998382 DOI: 10.1038/s41433-022-02030-5] [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: 04/08/2021] [Revised: 02/15/2022] [Accepted: 03/11/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To report the demographics and ocular features of myasthenia gravis in the paediatric population. METHODS Retrospective revision of the medical records of all patients younger than 18 years of age with myasthenia who were examined at Great Ormond Street Hospital between the 1st of January 2016 and 1st of January 2020. RESULTS A total of 49 children were assessed during the 4-year period. There was a female predominance, with only 12 males (24.5%). 26 children (53.1%) had juvenile myasthenia gravis (JMG) while 18 (36.7%) had congenital myasthenic syndrome (CMS). 4 patients (8.2%) were diagnosed with probable CMS while 1 (2.0%) was classified as probable JMG. The mean age at diagnosis was 5.3 years old (SD 3.9) whereas the mean age at onset was 3.7 years old (SD 3.9). Almost half of the children (49%) had ocular involvement, present in 19 patients in the JMG group (70.4%) and in 5 children (22.7%) in the CMS cohort. Ptosis was the most common sign at presentation, seen in 32 patients (65.3%). Nine patients (18.4%) presented with a squint and another 7 (14.3%) developed it later on. Anti-acetylcholine receptor antibodies were positive in 18 of the 26 JMG patients (69.2%) whereas identifiable mutations were found in the 18 CMS patients (100%). Pyridostigmine was the drug of choice in our series, used by thirty-three patients (67.3%). The majority of the patients (73.5%) improved after treatment. CONCLUSIONS JMG was the most common type of paediatric MG, specifically the ocular form. Ptosis was the most common sign at presentation. The majority of the patients improved after medical treatment.
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Affiliation(s)
- Natalia Arruti
- Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK.
| | - Pinki Munot
- Dubowitz Neuromuscular Centre, Great Ormond Street Hospital for Children, London, UK
| | - Richard Bowman
- Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK
- Ulverscroft Vision Research Group, UCL Great Ormond Street Institute for Child Health, 30 Guilford Street, London, WC1N 1EH, UK
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Markow MB, Ren D, Andrews A, DiFazio M. Isolated Unilateral Ptosis in a 5-year-old Boy. Pediatr Rev 2022; 43:721-723. [PMID: 36450634 DOI: 10.1542/pir.2020-004176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
| | | | - Alex Andrews
- Division of Neurology, Children's National Hospital, Washington, DC
| | - Marc DiFazio
- Division of Neurology, Children's National Hospital, Washington, DC
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15
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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.
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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
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16
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Hsu WY, Lin PC, Liu YC, Lin LC. Alopecia and colon ulcers following azathioprine use in a patient with myasthenia gravis: A case report. Medicine (Baltimore) 2022; 101:e29986. [PMID: 35984164 PMCID: PMC9388021 DOI: 10.1097/md.0000000000029986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Azathioprine is a purine analog (PA) used to treat myasthenia gravis (MG). However, some patients are sensitive to azathioprine and develop severe side effects, such as leukopenia, alopecia, and diarrhea soon after using the medication. Pharmacogenetics plays a crucial role in such intolerance. PATIENT CONCERNS A 16-year-old woman with MG developed hair loss, pancytopenia, bloody diarrhea, and fever shortly after azathioprine treatment. DIAGNOSIS Pharmacogenetic analysis revealed compound heterozygosity of the nudix hydrolase 15 (NUDT15) gene, which led to suppressed NUDT15 function. Colonoscopy revealed large ulcers with polypoid lesions in the terminal ileum, cecum, ascending colon, and rectum. These are the characteristics of inflammatory bowel disease (IBD). INTERVENTIONS Sanger sequencing of NUDT15 gene and colonoscopy for bloody stool evaluation. OUTCOMES The patient recovered completely from this acute episode after discontinuation of azathioprine treatment. Her hemogram turned back to normal range. There was also no blood in stool during follow-up. LESSONS Pharmacogenetic effects should be considered when prescribing PA medication. The possibility of secondary or concomitant autoimmune diseases must always be considered in patients with MG.
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Affiliation(s)
- Wan-Yi Hsu
- Division of Pediatric Emergency, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pei-Chin Lin
- Division of Hematology-Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Ching Liu
- Division of Cardiology and Pulmonary, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Lung-Chang Lin
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Neurology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- *Correspondence: Lung-Chang Lin, PhD, Division of Neurology, Department of Pediatrics, Kaohsiung Medical University Hospital, No. 100, Tzyou 1st Road, Kaohsiung 807, Taiwan (e-mail: )
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AlManea SM, AlHadlaq MA, AlBuqmi NM, AlGomaiz SS. The Dental Management of Pediatric Patient Diagnosed with Myasthenia Gravis: A Case Report. Eur J Dent 2022; 16:710-714. [PMID: 35728606 PMCID: PMC9507565 DOI: 10.1055/s-0042-1745773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Myasthenia gravis (MG) is a rare autoimmune neurological disorder characterized by muscle weakness and can vary in severity from the mild form that affects the ocular muscles only to the generalized form that affects the other muscle groups. The prevalence of MG is 150 to 200 per million population over the past 50 years, and approximately 10% of these cases are pediatric patients where the disease onset starts before the age of 18 years. The etiology of MG is due to the blockage of neuromuscular transmission by circulating autoantibodies targeting mainly the nicotinic acetylcholine receptor (AChR) and associated proteins in the postsynaptic membrane of skeletal muscles. In MG patients, dental treatment is challenging due to the nature of the condition and its complexity. Moreover, dentists treating MG patients should acquire knowledge about the disease background and the special considerations that need to be taken. In this case report, our aim was to raise awareness about MG among dentists and discuss the dental management of the patients who have this disease and the precautions that should be taken. This case report presents a pediatric MG patient with poor oral hygiene, multiple decayed teeth, dental fluorosis, tongue thrust oral habit that led to anterior open-bite and uncomplicated crown fracture of the upper permanent central incisors. The decision was made to treat the patient under general anesthesia because of the medical condition and the extent of the dental treatment. In the process of preparing the patient for surgery, the patient was cleared from the treating physicians and was admitted under neurology care as per the primary physician. On the day of surgery, the patient received full-mouth dental rehabilitation under general anesthesia, including pulp therapy, crowns, restorations, and extractions. Furthermore, she was seen regularly in recall visits every 3 months.
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Affiliation(s)
- Saad M AlManea
- Department of Pediatric Dentistry, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Mashael A AlHadlaq
- Department of Pediatric Dentistry, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Noura M AlBuqmi
- Department of Pediatric Dentistry, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Sultan S AlGomaiz
- Department of Dental Services, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
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18
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Yavuz P, Demir OO, Ozsurekci Y, Ozen S, Anlar B, Haliloglu G. New-Onset Ocular Myasthenia after Multisystem Inflammatory Syndrome in Children. J Pediatr 2022; 245:213-216. [PMID: 35231493 PMCID: PMC8882031 DOI: 10.1016/j.jpeds.2022.02.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/13/2022]
Abstract
Neurologic complications have been associated with multisystem inflammatory syndrome in children, possibly involving autoimmune mechanisms. Here, we report a 6-year-old girl who developed myasthenia 11 weeks after severe acute respiratory syndrome coronavirus 2 infection and 8 weeks after the onset of severe multisystem inflammatory syndrome in children.
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Affiliation(s)
- Pınar Yavuz
- Division of Pediatric Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Osman Oguz Demir
- Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Yasemin Ozsurekci
- Division of Pediatric Infectious Diseases, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Seza Ozen
- Division of Pediatric Rheumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Banu Anlar
- Division of Pediatric Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Goknur Haliloglu
- Division of Pediatric Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
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19
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Myasthenia Gravis Masquerading as Status Asthmaticus. Case Rep Pediatr 2022; 2021:6959701. [PMID: 34992892 PMCID: PMC8727132 DOI: 10.1155/2021/6959701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/23/2021] [Accepted: 12/03/2021] [Indexed: 11/18/2022] Open
Abstract
Myasthenia gravis, an autoimmune disorder of neuromuscular transmission, can lead to varying degrees of weakness and fatigability of the skeletal musculature. Juvenile myasthenia gravis accounts for 10–15% of all cases of myasthenia gravis. The clinical presentation of juvenile myasthenia gravis varies tremendously, which presents itself as a diagnostic challenge for clinicians. We report a case of a 15-year-old female with mild intermittent asthma presenting with shortness of breath. Acute onset of dyspnea is a common chief complaint amongst the pediatric population with a broad differential diagnosis. Our patient was presumptively treated for status asthmaticus and required invasive mechanical ventilation. After extubating, the patient showed persistent ptosis, which led to the eventual work-up of myasthenia gravis. Upon further review, this patient had months of intermittent symptoms including ptosis and fatigue which went previously undiagnosed. This case demonstrates that dyspnea in an asthmatic can occur from nonairway processes and, if missed, may result in overtreatment of asthma or delayed diagnosis of an important neuromuscular process.
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20
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Barišić N, Turudić D, Marić LS, Tešović G. Vaccination in pediatric acquired inflammatory immune-mediated neuromuscular disorders. Eur J Paediatr Neurol 2022; 36:159-176. [PMID: 34998097 DOI: 10.1016/j.ejpn.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/15/2021] [Accepted: 12/18/2021] [Indexed: 11/26/2022]
Abstract
AIM To analyse literature data on vaccine related induction, worsening of the disease and disease reccurrences as well as vaccine safety and efficacy among pediatric patients with acquired inflammatory immune-mediated neuromuscular disorders (NMD). METHODS Medline, Pub Med and Scopus database search from 1975 to 2020 focused on pediatric age was conducted including peer reviews, meta analyses and epidemiological studies on vaccination and Guillain-Barré syndrome (GBS), Bell's palsy, optic neuritis (ON), myasthenia gravis (MG), chronic inflammatory demyelinating polyneuropathy (CIDP) and immune-mediated inflammatory myopathy (IM). RESULTS AND CONCLUSION s: There are no strong evidence supporting relationship between vaccination with different pediatric vaccines and development of first episodes or reccurrences of GBS, Bell's palsy, optic neuritis (ON), juvenile MG, CIDP, and IM. The vaccination and revaccination with inactivated vaccines is considered safe in children with medical history of GBS, Bell's palsy, ON, MG and IM. Caution when immunization against influenza, quadrivalent conjugated meningococcal vaccine (MCV4) and pneumococcal disease and avoiding tetanus toxoid immunization in CIDP patients is suggested. Patients with immune mediated acquired NMD should be vaccinated with live vaccines before the initiation of immunosupressive treatment. Immunosuppressed patients with low protective antibody titers should be considered for revaccination.
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Affiliation(s)
- Nina Barišić
- Department of Pediatrics, Clinical Medical Centre, Zagreb, Croatia; University of Zagreb, School of Medicine, Zagreb, Croatia.
| | - Daniel Turudić
- Department of Pediatrics, Clinical Medical Centre, Zagreb, Croatia
| | - Lorna Stemberger Marić
- University of Zagreb, School of Medicine, Zagreb, Croatia; University Hospital for Infectious Diseases "Dr. Fran Mihaljević", Zagreb, Croatia
| | - Goran Tešović
- University of Zagreb, School of Medicine, Zagreb, Croatia; University Hospital for Infectious Diseases "Dr. Fran Mihaljević", Zagreb, Croatia
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21
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Jones DL, Ma J, Yang M, Duong A, Richani K. Pediatric Ptosis: A Review of Less Common Causes. Int Ophthalmol Clin 2022; 62:177-202. [PMID: 34965234 DOI: 10.1097/iio.0000000000000389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Santiago Gonçalves C, Nunes Marques MI, Antunes S, Serrano A. Transient Neonatal Myasthenia Gravis: A Case Report. Cureus 2021; 13:e20592. [PMID: 35103168 PMCID: PMC8782634 DOI: 10.7759/cureus.20592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 12/02/2022] Open
Abstract
Myasthenia gravis (MG) in the neonate is usually due to placentally transferred antibodies to the acetylcholine receptor (AChR), resulting in impaired neuromuscular transmission. It occurs in 10%-15% of newborns born to women with MG. We present a male newborn admitted to the neonatal intensive care unit (NICU) 38 hours after birth due to feeding difficulties and choking episodes. He was born to a mother with MG after an uneventful, well-followed pregnancy. Physical examination revealed a weak cry, persistent inability to fully close his eyelids, weak facial mimic, and a mouth that was always held open with swallowing and sucking difficulties. He assumed a frog leg position and showed generalized hypotonia with marked head lag. No respiratory distress was present. Laboratory evaluation showed an elevated anti-acetylcholine receptor antibody concentration (36.30 nmol/L; normal: <0.25 nmol/L). Transient neonatal myasthenia gravis (TNMG) was admitted, and an anticholinesterase agent was initiated. Given that he showed only a mild clinical improvement, two doses of immunoglobulin were administered on the eighth and ninth days of life. Anticholinesterase agents were progressively reduced and suspended on day 31 of life with clinical improvement. He was discharged home at one month of life clinically asymptomatic. He was evaluated one month later and was doing well. A positive history of MG in the mother associated with a suggestive physical examination may be sufficient to make the diagnosis of transient neonatal MG, emphasizing the importance of good medical history. With prompt diagnosis and appropriate management, most newborns experience spontaneous remission after a period of weeks to months.
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23
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Chen WJ, Yu X, Yuan XR, Chen BJ, Cai N, Zeng S, Sun YS, Li HW. The Role of IL-36 in the Pathophysiological Processes of Autoimmune Diseases. Front Pharmacol 2021; 12:727956. [PMID: 34675805 PMCID: PMC8523922 DOI: 10.3389/fphar.2021.727956] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 09/13/2021] [Indexed: 12/15/2022] Open
Abstract
A member of the interleukin (IL)-1 superfamily was IL-36, which contained IL-36α, IL-36β, IL-36γ, and IL-36Ra. Heterotrimer complexes, consisting of heterodimeric receptor complexes and IL-36 agonist, gave signals through intracellular functional domains, so as to bind to downstream proteins and induce inflammatory response. IL-36 agonists upregulated mature-associated CD80, CD86, MHCII, and inductively produced several pro-inflammatory cytokines through the IL-36R-dependent manner in dendritic cells (DCs). Besides, DCs had the ability to initiate the differentiation of helper T (Th) cells. Up to date, the role of IL-36 in immunity, inflammation and other diseases is of great importance. Additionally, autoimmune diseases were characterized by excessive immune response, resulting in damage and dysfunction of specific or multiple organs and tissues. Most autoimmune diseases were related to inflammatory response. In this review, we will conclude the recent research advances of IL-36 in the occurrence and development of autoimmune diseases, which may provide new insight for the future research and the treatment of these diseases.
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Affiliation(s)
- Wen-Jian Chen
- Department of Orthopaedics, Anhui Provincial Children's Hospital, Hefei, China
| | - Xiao Yu
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, School of Pharmacy, Anhui Medical University, Hefei, China
| | - Xin-Rong Yuan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Bang-Jie Chen
- The First Clinical Medical College of Anhui Medical University, Hefei, China
| | - Na Cai
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, School of Pharmacy, Anhui Medical University, Hefei, China
| | - Shuo Zeng
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, School of Pharmacy, Anhui Medical University, Hefei, China
| | - Yuan-Song Sun
- Department of Emergency Surgery, The Second Hospital of Anhui Medical University, Hefei, China
| | - Hai-Wen Li
- Department of Gastroenterology, The Third Affiliated Hospital of Anhui Medical University, Hefei, China.,Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Fc-Receptor Targeted Therapies for the Treatment of Myasthenia gravis. Int J Mol Sci 2021; 22:ijms22115755. [PMID: 34071155 PMCID: PMC8198115 DOI: 10.3390/ijms22115755] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 12/16/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease in which immunoglobulin G (IgG) antibodies (Abs) bind to acetylcholine receptors (AChR) or to functionally related molecules in the postsynaptic membrane at the neuromuscular junction. IgG crystallizable fragment (Fc)-mediated effector functions, such as antibody-dependent complement deposition, contribute to disease development and progression. Despite progress in understanding Ab-mediated disease mechanisms, immunotherapy of MG remained rather unspecific with corticosteroids and maintenance with immunosuppressants as first choice drugs for most patients. More specific therapeutic IgG Fc-based platforms that reduce serum half-life or effector functions of pathogenic MG-related Abs are currently being developed, tested in clinical trials or have recently been successfully translated into the clinic. In this review, we illustrate mechanisms of action and clinical efficacies of emerging Fc-mediated therapeutics such as neonatal Fc receptor (FcRn)-targeting agents. Furthermore, we evaluate prospects of therapies targeting classical Fc receptors that have shown promising therapeutic efficacy in other antibody-mediated conditions. Increased availability of Fc- and Fc receptor-targeting biologics might foster the development of personalized immunotherapies with the potential to induce sustained disease remission in patients with MG.
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Lu H, Wang H, Sun P, Wang J, Li S, Xu T. MiR-522-3p inhibits proliferation and activation by regulating the expression of SLC31A1 in T cells. Cytotechnology 2021; 73:483-496. [PMID: 34149179 DOI: 10.1007/s10616-021-00472-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/22/2021] [Indexed: 11/25/2022] Open
Abstract
We investigated the role of miR-522-3p in thymoma-associated myasthenia gravis (TAMG), and the mechanism of action in T cells. The miR-522-3p expression in normal serum, non-thymoma MG patient serum and TAMG patient serum and tissues was detected by quantitative real-time PCR (qRT-PCR), respectively. We assessed miR-522-3p expression in Jurkat cells and human CD4+ T cells after activation by anti-CD3 and anti-CD28 using qRT-PCR. The viability, proliferation, cycle distribution and the levels of CD25, CD69, interleukin-2 (IL-2) and IL-10 in transfected Jurkat cells were detected by Cell counting kit-8, 5-ethynyl-2'-deoxyuridine (EdU), flow cytometry, qRT-PCR, respectively. Targeting relationships of miR-522-3p and SLC31A1 were predicted and validated by bioinformatics analysis and dual-luciferase reporter. The viability, proliferation, cycle distribution and the levels of SLC31A1, CD25, CD69, IL-2 and IL-10 in transfected Jurkat cells were detected by above methods and western blot. The miR-522-3p expression was declined in TAMG and activated T cells. MiR-522-3p inhibitor promoted cell viability, EdU positive cells, cycle progression, and the level of CD25, CD69, IL-2 and IL-10 in Jurkat cells, while the effect of miR-522-3p mimic was the opposite. SLC31A1 was targeted by miR-522-3p, and miR-522-3p inhibited SLC31A1 expression. Overexpressed SLC31A1 reversed the inhibitory effects of miR-522-3p mimic on cell viability, EdU positive cell, cycle progression, and the levels of IL-2 and IL-10 in transfected Jurkat cells. MiR-522-3p expression was down-regulated in TAMG, and miR-522-3p inhibited proliferation and activation by regulating SLC31A1 expression in T cells.
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Affiliation(s)
- Hengxiao Lu
- Department of Thoracic Surgery, Weifang People's Hospital, No.151 Guangwen Road, Kuiwen District, Weifang City, 261041 Shangdong Province China
| | - Hao Wang
- Department of Thoracic Surgery, Weifang People's Hospital, No.151 Guangwen Road, Kuiwen District, Weifang City, 261041 Shangdong Province China
| | - Peidao Sun
- Department of Thoracic Surgery, Changle People's Hospital, Weifang, China
| | - Jiang Wang
- Department of Thoracic Surgery, Weifang People's Hospital, No.151 Guangwen Road, Kuiwen District, Weifang City, 261041 Shangdong Province China
| | - Shuhai Li
- Department of Thoracic Surgery, Qilu Hospital, Cheeloo College of Medicine, Jinan, China
| | - Tongzhen Xu
- Department of Thoracic Surgery, Weifang People's Hospital, No.151 Guangwen Road, Kuiwen District, Weifang City, 261041 Shangdong Province China
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26
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Prior DE, Cooper BA, Zhang B, Ghosh PS. Developing outcome measures of disease activity in pediatric myasthenia. Muscle Nerve 2021; 63:751-757. [PMID: 33604899 DOI: 10.1002/mus.27208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/14/2021] [Accepted: 02/16/2021] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Pediatric myasthenia encompasses juvenile myasthenia gravis (JMG) and congenital myasthenic syndrome (CMS), which are chronic disorders with fluctuating symptoms amenable to medical therapy. Disease activity and treatment response may be difficult to assess, but, unlike adults, outcome measures have not been developed in children. METHODS The study was performed in children (0-18 years of age) at the neuromuscular center of a pediatric hospital over a 3-year period. Patients were recruited prospectively as part of their routine clinical care. Demographic data, diagnosis (JMG/CMS), and the following scales were recorded at each visit: Myasthenia Gravis Foundation of America (MGFA) class, Myasthenia Gravis Composite (MGC), and Pediatric Myasthenia-Quality of Life 15 (PM-QOL15). RESULTS Thirty-three patients (24 JMG, 9 CMS) were included in the study, 22 had two or more visits. We established known-groups validity of the MGC and PM-QOL15 scores as compared with the MGFA class. To establish concurrent validity, we constructed a receiver-operating characteristic curve and calculated threshold values of MGC and PM-QOL15 with optimal sensitivity and specificity for identifying a patient with more severe (MGFA III or higher) disease. Finally, we demonstrated the concordance between the MGC and PM-QOL15 by their statistically significant positive Pearson and Spearman correlations. DISCUSSION Our study suggests that MGC and PM-QOL15 are important disease outcome measures in pediatric myasthenia that are easy to administer and provide reliable assessment of disease activity in the clinic setting. Further studies are needed to validate their use for pediatric clinical research trials.
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Affiliation(s)
- Devin E Prior
- Department of Neurology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | | | - Bo Zhang
- Department of Neurology and ICCTR Biostatistics and Research Design Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Partha S Ghosh
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
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Outcomes of Juvenile Myasthenia Gravis: A Comparison of Robotic Thymectomy With Medication Treatment. Ann Thorac Surg 2021; 113:295-301. [PMID: 33482164 DOI: 10.1016/j.athoracsur.2020.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 09/20/2020] [Accepted: 12/30/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The study aimed to compare the clinical outcomes of patients with juvenile myasthenia gravis (MG) who underwent robotic thymectomy with that of those who only received medication therapy. METHODS We retrospectively reviewed patients who visited our institution for the diagnosis or treatment of MG with an age at onset younger than 18 years. Patients who underwent thymectomy comprised the surgical group and those who received only medication therapy comprised the nonsurgical group. The clinical outcomes were assessed according to the Myasthenia Gravis Foundation of America Post-Intervention Status. RESULTS Forty-seven patients (35 female, 12 male) were included as the surgical group and 20 patients (15 female, 5 male) comprised the nonsurgical group. Significant differences were observed between the surgical and nonsurgical groups in antibody against acetylcholinesterase receptor (91.5% vs 65%; P = .012), disease duration (median 16 [interquartile range, 7-25] months vs 96 [interquartile range, 42-480] months; P < .001), and corticosteroids requirement (53.2% vs 15%; P = .004) at baseline. Kaplan-Meier analysis showed a higher cumulative probability of complete stable remission in the surgical group (P = .002) compared with the nonsurgical group. Moreover, thymectomy (hazard ratio, 3.842; 95% confidence interval, 1.116-13.230; P = .033) and age at onset (hazard ratio, 0.89; 95% confidence interval, 0.80-0.99; P = .037) were still associated with the achievement of complete stable remission in the multivariable analysis. Furthermore, a significant steroid-sparing effect was observed in the surgical group but not in the nonsurgical group. CONCLUSIONS Robotic thymectomy seems to be more effective than medication therapy on juvenile MG in terms of inducing remission and reducing the use of corticosteroids.
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Grasso F, De Leonibus L, Bertozzi M, Sica M, Angotti R, Luzzi L, Molinaro F, Messina M, Paladini P. Robotic-assisted thoracoscopy thymectomy for juvenile myasthenia gravis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Ipe TS, Meyer EK, Sanford KW, Joshi SK, Wong ECC, Raval JS. Use of therapeutic plasma exchange for pediatric neurological diseases. J Clin Apher 2020; 36:161-176. [PMID: 33063869 DOI: 10.1002/jca.21850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/10/2020] [Accepted: 10/02/2020] [Indexed: 12/19/2022]
Abstract
Therapeutic plasma exchange is used to treat neurological diseases in the pediatric population. Since its first use in pediatric patients with hepatic coma in the form of manual whole blood exchange, therapeutic plasma exchange has been increasingly used to treat these disorders of the nervous system. This expansion is a result of improved techniques and apheresis instruments suitable for small children, as well as the recognition of its applicability to many diseases in the pediatric population. This review provides a historical overview of the use of therapeutic apheresis in children and highlights the most common applications for therapeutic plasma exchange to treat neurological disorders in children.
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Affiliation(s)
- Tina S Ipe
- Department of Pathology and Laboratory Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Erin K Meyer
- American Red Cross, Columbus, Ohio, USA.,Department of Pathology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kimberly W Sanford
- Department of Pathology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sarita K Joshi
- Department of Hematology/Oncology and Bone Marrow Transplant, University of Washington, Seattle, Washington, USA
| | - Edward C C Wong
- Department of Pediatrics and Pathology, George Washington School of Medicine and Health Sciences, Washington, District of Columbia, USA.,Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Jay S Raval
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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Zingariello CD, Elder ME, Kang PB. Rituximab as Adjunct Maintenance Therapy for Refractory Juvenile Myasthenia Gravis. Pediatr Neurol 2020; 111:40-43. [PMID: 32951658 DOI: 10.1016/j.pediatrneurol.2020.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Juvenile myasthenia gravis is a pediatric autoimmune disorder of the neuromuscular junction associated with substantial morbidity, for which standard therapies are not always efficacious. The objective of our study was to assess the tolerability and efficacy of rituximab use in children with refractory juvenile myasthenia gravis. METHODS We conduced a retrospective cohort study at a single tertiary care referral center to evaluate children with juvenile myasthenia gravis who were treated with rituximab. The clinical status of these participants before and after initiation of rituximab therapy was measured, focusing on numbers of hospital admissions, numbers of immunomodulatory or immunosuppressive medications needed, and Myasthenia Gravis Foundation of America severity class. RESULTS Five children with juvenile myasthenia gravis were ascertained who received rituximab as part of their regimen, four of whom had elevated acetylcholine receptor antibodies and one of whom had elevated muscle-specific kinase antibodies. After initiation of rituximab therapy, all participants experienced reduced numbers of immunomodulatory medications during the follow-up period (mean 11.6 months). Four of the five subjects experienced fewer juvenile myasthenia gravis-related hospital admissions and reduced (improved) Myasthenia Gravis Foundation of America classes, with no subjects having moderate or severe symptoms following treatment with rituximab. No significant adverse events were recorded for any of the participants. CONCLUSION Rituximab was well-tolerated and efficacious in this juvenile myasthenia gravis cohort. The beneficial effect of rituximab was most pronounced in the one participant with muscle-specific kinase antibodies.
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Affiliation(s)
- Carla D Zingariello
- Division of Pediatric Neurology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Melissa E Elder
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Peter B Kang
- Division of Pediatric Neurology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida; Department of Neurology and Department of Molecular Genetics and Microbiology, University of Florida College of Medicine, Gainesville, Florida.
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Corrado B, Giardulli B, Costa M. Evidence-Based Practice in Rehabilitation of Myasthenia Gravis. A Systematic Review of the Literature. J Funct Morphol Kinesiol 2020; 5:jfmk5040071. [PMID: 33467286 PMCID: PMC7739309 DOI: 10.3390/jfmk5040071] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 12/28/2022] Open
Abstract
Myasthenia gravis is a rare neuromuscular disorder characterized by muscle weakness and fatigue. This review analyzes the most recent evidence regarding the effectiveness and safety of different rehabilitative approaches to the disease. The review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 365 articles were found in the main scientific databases. Applying the inclusion/exclusion criteria, 11 studies were admitted to the final phase of the review. Three different rehabilitative approaches were identified: physical training, respiratory training, and balance training. All rehabilitative modalities contributed to enhancing functional outcomes, reducing fatigue, and improving quality of life, but currently none can be recommended over another for the lack of cross-comparative studies. The included studies showed methodological quality from low to fair. Despite the range of rehabilitative interventions available, there is a lack of high-quality evidence. However, this review suggests that a multidisciplinary rehabilitation approach should be recommended to people with myasthenia gravis, and above all, for those with mild to moderate symptomatology.
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Affiliation(s)
- Bruno Corrado
- Department of Public Health, University Federico II of Naples, Via S. Pansini n.5, 80131 Naples, Italy;
- Correspondence: ; Tel.: +39-0817462796; Fax: +39-0817462881
| | - Benedetto Giardulli
- Department of Public Health, University Federico II of Naples, Via S. Pansini n.5, 80131 Naples, Italy;
| | - Massimo Costa
- Department of Polyspecialistic Medicine, Cardarelli Hospital, Via A. Cardarelli, 80131 Naples, Italy;
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Yan C, Zhao R, Song J, Feng X, Xi J, Luo S, Zhong H, Zhou S, Li W, Zhao C. Comparison of anti-acetylcholine receptor profiles between Chinese cases of adult- and juvenile-onset myasthenia gravis using cell-based assays. J Neuroimmunol 2020; 349:577403. [PMID: 32992216 DOI: 10.1016/j.jneuroim.2020.577403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/29/2020] [Accepted: 09/19/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Juvenile-onset myasthenia gravis (JOMG) is a unique clinical subtype in China, featured by a higher prevalence of ocular myasthenia gravis (OMG), higher seronegativity of acetylcholine receptor (AChR) antibodies, and better prognosis than that in adult-onset myasthenia gravis (AOMG). We previously identified low-affinity AChR antibodies in Chinese JOMG patients using cell-based assays (CBAs), indicating a predominantly AChR antibody-positive profile. Here, we further screened AChR antibodies in both Chinese AOMG and JOMG patients by CBAs. MATERIALS AND METHODS We recruited patients with MG who had not received prednisone or immunosuppressive therapies between June 2015 and June 2019, and divided them into AOMG and JOMG subgroups according to their ages at the time of recruitment. Clinical information and blood samples were collected. Serum AChR antibodies were detected by CBAs in HEK293T cells expressing clustered adult and fetal AChRs, as well as by enzyme-linked immunosorbent assays (ELISAs). Differences in AChR antibody profiles between AOMG and JOMG subgroups were determined. RESULTS A total of 239 patients with MG were enrolled in the present study, including 121 AOMG and 118 JOMG patients. Based on ELISAs, 74.4% of AOMG (90/121) and 59.3% of JOMG (70/118) patients were anti-AChR positive (p = 0.02). However, CBAs yielded equal anti-AChR positivities (p = 0.64), as indicated by 80.2% of AOMG patients (97/121) and 77.1% of JOMG patients (91/118). Furthermore, among AOMG patients, 67.8% (82/121) were positive for both adult and fetal AChR antibodies, 5.8% (7/121) were positive for only adult AChR antibodies, and 6.6% (8/121) were positive for only fetal AChR antibodies, while these rates were 50.8% (60/118), 21.2% (25/118), and 5.1% (6/118), respectively, in JOMG cohorts (p < 0.01). Twenty-nine AOMG patients and 10 JOMG patients underwent IgG subclassification of AChR antibodies, which were all confirmed to be predominantly IgG1. CONCLUSIONS The positive rates of AChR antibodies did not differ between Chinese AOMG and JOMG patients, as revealed by CBAs. Furthermore, the screened AChR antibodies were predominantly IgG1 in both AOMG and JOMG patients.
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Affiliation(s)
- Chong Yan
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Rui Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jie Song
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xuelin Feng
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangdong 510080, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Huahua Zhong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Shuizhen Zhou
- Department of Neurology, Children's Hospital of Fudan University, Shanghai 200040, China
| | - Wenhui Li
- Department of Neurology, Children's Hospital of Fudan University, Shanghai 200040, China.
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China; Department of Neurology, Jing'an District Center Hospital of Shanghai, Fudan University, Shanghai 200040, China.
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Li JW, Fang F, Ren XT, Zhang WH, Yang XY, Ren CH, Gong S, Lyu JL, Wang XH, Wang X, Wu HS, Ding CH. [Clinical effect of tacrolimus in the treatment of myasthenia gravis in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22:964-969. [PMID: 32933627 PMCID: PMC7499454 DOI: 10.7499/j.issn.1008-8830.2004215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/28/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of tacrolimus in the treatment of children with myasthenia gravis (MG). METHODS A total of 28 children with MG were treated with tacrolimus. MG-Activities of Daily Living (MG-ADL) scale was used to assess clinical outcome and safety after 1, 3, 6, 9, and 12 months of treatment. RESULTS After tacrolimus treatment, the MG-ADL score at 1, 3, 6, 9 and 12 months was lower than that at baseline (P<0.05), and the MG-ADL score showed a gradually decreasing trend. The response rates to tacrolimus treatment at 1, 3, 6, 9, and 12 months were 59%, 81%, 84%, 88%, and 88% respectively. At 6, 9, 12, and 18 months of treatment, 4, 13, 14, and 15 children respectively were withdrawn from prednisone. No recurrence was observed during treatment. Major adverse reactions/events were asymptomatic reduction in blood magnesium in 5 children and positive urine occult blood in 1 child, which turned negative without special treatment, and tacrolimus was not stopped due to such adverse reactions/events. One child was withdrawn from tacrolimus due to recurrent vomiting. According to CYP3A5 genotypes, all of the patients were divided into two groups: slow metabolic type (n=19) and non-slow metabolic type (fast metabolic type + intermediate type; n=9). The non-slow metabolism group received a higher dose of tacrolimus, but had a lower trough concentration of tacrolimus than the slow metabolism group (P<0.05). The slow metabolism group had a higher response rates to tacrolimus treatment than the non-slow metabolism group (P<0.05). CONCLUSIONS Tacrolimus appears to be effective and safe in the treatment of children with MG and is thus an option for immunosuppressive therapy. CYP3A5 genotyping has a certain guiding significance for determining the dosage of tacrolimus.
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Affiliation(s)
- Jiu-Wei Li
- Department of Neurology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China.
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Olewnik LAJ, MacHue LD. Case 1: Weakness and Gait Instability in a 4-year-old Girl. Pediatr Rev 2020; 41:357-360. [PMID: 32611800 DOI: 10.1542/pir.2018-0244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Lcdr Adam J Olewnik
- Medical Corps, United States Navy, Naval Medical Center Camp Lejeune, North Carolina
| | - Lt Daniel MacHue
- Medical Corps, United States Navy, Naval Medical Center Camp Lejeune, North Carolina
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Pseudopartial Third Nerve Palsy as the Presenting Sign of Ocular Myasthenia Gravis. Optom Vis Sci 2020; 97:377-382. [DOI: 10.1097/opx.0000000000001512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Affiliation(s)
| | - Sheebu V Chacko
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Shabana Yusuf
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
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S1P/S1P Receptor Signaling in Neuromuscolar Disorders. Int J Mol Sci 2019; 20:ijms20246364. [PMID: 31861214 PMCID: PMC6941007 DOI: 10.3390/ijms20246364] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/06/2019] [Accepted: 12/13/2019] [Indexed: 12/13/2022] Open
Abstract
The bioactive sphingolipid metabolite, sphingosine 1-phosphate (S1P), and the signaling pathways triggered by its binding to specific G protein-coupled receptors play a critical regulatory role in many pathophysiological processes, including skeletal muscle and nervous system degeneration. The signaling transduced by S1P binding appears to be much more complex than previously thought, with important implications for clinical applications and for personalized medicine. In particular, the understanding of S1P/S1P receptor signaling functions in specific compartmentalized locations of the cell is worthy of being better investigated, because in various circumstances it might be crucial for the development or/and the progression of neuromuscular diseases, such as Charcot-Marie-Tooth disease, myasthenia gravis, and Duchenne muscular dystrophy.
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Broser PJ, Lütschg J. Die Bedeutung neurophysiologischer Methoden in der Abklärung neuropädiatrischer und neuromuskulärer Erkrankungen. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-00819-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Iolascon G, Paoletta M, Liguori S, Curci C, Moretti A. Neuromuscular Diseases and Bone. Front Endocrinol (Lausanne) 2019; 10:794. [PMID: 31824418 PMCID: PMC6886381 DOI: 10.3389/fendo.2019.00794] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 10/30/2019] [Indexed: 02/05/2023] Open
Abstract
Neuromuscular diseases (NMDs) are inherited or acquired conditions affecting skeletal muscles, motor nerves, or neuromuscular junctions. Most of them are characterized by a progressive damage of muscle fibers with reduced muscle strength, disability, and poor health-related quality of life of affected patients. In this scenario, skeletal health is usually compromised as a consequence of modified bone-muscle cross-talk including biomechanical and bio-humoral issues, resulting in increased risk of bone fragility and fractures. In addition, NMD patients frequently face nutritional issues, including malnutrition due to feeding disorders and swallowing problems that might affect bone health. Moreover, in these patients, low levels of physical activity or immobility are common and might lead to overweight or obesity that can also interfere with bone strength features. Also, vitamin D deficiency could play a critical role both in the pathogenesis and in the clinical scenario of many NMDs, suggesting that its correction could be useful in maintaining or enhancing bone health, especially in the early phases of NMDs. Last but not least, specific disease-modifying drugs, available for some NMDs, are frequently burdened with adverse effects on bone tissue. For example, glucocorticoid therapy, standard of care for many muscular dystrophies, prolongs long-term survival in treated patients; nevertheless, high dose and/or chronic use of these drugs are a common cause of secondary osteoporosis. This review addresses the current state of knowledge about the factors that play a role in determining bone alterations reported in NMDs, how these factors can modify the biological pathways underlying bone health, and which are the available interventions to manage bone involvement in patients affected by NMDs. Considering the complexity of care of these patients, an interdisciplinary and multimodal management strategy based on both pharmacological and non-pharmacological interventions is recommended, particularly targeting musculoskeletal issues that are closely related to functional independence as well as social implications.
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Affiliation(s)
- Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
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Yan C, Li W, Song J, Feng X, Xi J, Lu J, Zhou S, Zhao C. Cell-Based Versus Enzyme-Linked Immunosorbent Assay for the Detection of Acetylcholine Receptor Antibodies in Chinese Juvenile Myasthenia Gravis. Pediatr Neurol 2019; 98:74-79. [PMID: 31307830 DOI: 10.1016/j.pediatrneurol.2019.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/16/2019] [Accepted: 01/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients in China with juvenile-onset myasthenia gravis present early, with a high prevalence of purely ocular symptoms, spontaneous remission rates, and low antibody seropositivity. Antibody detection using a cell-based assay has been reported to increase the diagnostic sensitivity in adult-onset myasthenia gravis. However, this method in patients with juvenile-onset myasthenia gravis has not been investigated. METHODS Patients with juvenile-onset myasthenia gravis who had not received prednisone or immunosuppressive therapy were recruited between June 2015 and April 2018 at the Huashan Hospital. Clinical information was collected. Serum anti-acetylcholine receptor antibodies were detected via cell-based assay with HEK293T cells expressing acetylcholine receptor subunits and rapsyn. Additionally, the IgG antibody subclass was identified. RESULTS Eighty-two patients with juvenile-onset myasthenia gravis were enrolled in the current study. Among them, 48 patients were anti-acetylcholine receptor positive (58.5%) and 34 were seronegative (41.5%), as assessed via enzyme-linked immunosorbent assay. Cell-based assay yielded 63 positive subjects (76.8%) and 19 seronegative subjects (23.2%). All the enzyme-linked immunosorbent assay-positive samples showed robust immunofluorescence in the cell-based assay, whereas 15 of 34 enzyme-linked immunosorbent assay-negative patients (44.1%) were found to have low-affinity acetylcholine receptor antibodies. Among all the cell-based assay-positive patients, 41 were positive for both adult and fetal acetylcholine receptor antibodies (50.0%), 18 were found positive for only adult acetylcholine receptor antibodies (21.9%), and four were found to possess only fetal acetylcholine receptor antibodies (4.9%). Fifteen antibody-positive samples underwent subclassification and were confirmed to be IgG1 subclass predominant (n = 15, including eight adult and fetal acetylcholine receptor antibody positive, five only adult acetylcholine receptor antibody positive, and two only fetal acetylcholine receptor antibody positive). There were no significant differences in clinical features among patients with different antibody profiles. CONCLUSIONS The cell-based assay showed increased sensitivity in acetylcholine receptor antibody detection in Chinese patients with juvenile-onset myasthenia gravis, and most cases of Chinese juvenile-onset myasthenia gravis are still acetylcholine receptor autoantibody mediated. Furthermore, the antibodies detected are predominately of the IgG1 subclass.
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Affiliation(s)
- Chong Yan
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenhui Li
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Jie Song
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuelin Feng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Shuizhen Zhou
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China; Department of Neurology, Jing'an District Centre Hospital of Shanghai, Fudan University, Shanghai, China.
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Abstract
RATIONALE Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction that can be triggered by anticholinergic agents. PATIENT CONCERNS We present a 4-year-old female patient who was admitted to the outpatient clinic. She complained of drooped eyelids, which first appeared 2 days after taking a 200 mg dose of pyrantel pamoate. Past medical history is negative. DIAGNOSES AND TREATMENT She was hospitalized with a diagnosis of ocular type MG, and pyridostigmine (40 mg/day) treatment was started. OUTCOMES The patient recovered, and subsequently, the treatment dose was tapered. CONCLUSION Pyrantel is an antihelminthic that acts as an agonist of nicotinic acetylcholine receptors (AChRs) of nematodes and exerts its therapeutic effects by depolarizing their muscle membranes. Consequently, there may be an association between pyrantel pamoate and MG.
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Alvarez CN, John RM. The Pediatric Primary Care Management of Myasthenia Gravis. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2018.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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