High-dose intravenous gammaglobulin for myasthenia gravis

An update on the use of immunoglobulins as treatment for myasthenia gravis

INTRODUCTION

Myasthenia gravis (MG) is an antibody mediated disease where pathogenic antibodies interact with the acetylcholine receptor or other proteins at the post-synaptic neuromuscular junction. There is growing evidence that immunoglobulin infusions are beneficial for clinical exacerbations and chronic refractory disease and may be an option for patients unresponsive to conventional immunosuppressive therapies.

AREAS COVERED

We performed an extensive literature review, looking for evidence on the use of immunoglobulins for the treatment of MG, by conducting a search in MEDLINE (1946 to present), EMBASE (1947 to present) and Clinicaltrials.gov. We have included studies on the use of intravenous immunoglobulins (IVIG) and subcutaneous immunoglobulins (SCIG) for acute deterioration and chronic disease.

EXPERT OPINION

The use of IVIG in MG provides an option for rapid improvement in critical deterioration, being preferred over more invasive and less available therapies such as plasmapheresis. For refractory MG, the addition of IVIG can improve a patient's status and reduce the dosage of immunosuppressive medications. The alternative of SCIG is also effective and has advantages of infusion time flexibility, fewer side-effects, and patient independence. The safety and efficacy of both interventions, patient preferences and quality of life may direct therapeutic choices in the future.

Current Treatment of Myasthenia Gravis

Myasthenia gravis (MG) is the most extensively studied antibody-mediated disease in humans. Substantial progress has been made in the treatment of MG in the last century, resulting in a change of its natural course from a disease with poor prognosis with a high mortality rate in the early 20th century to a treatable condition with a large proportion of patients attaining very good disease control. This review summarizes the current treatment options for MG, including non-immunosuppressive and immunosuppressive treatments, as well as thymectomy and targeted immunomodulatory drugs.

Efficacy and Tolerability of Intravenous Immunoglobulin and Subcutaneous Immunoglobulin in Neurologic Diseases

PURPOSE

IV immunoglobulin (Ig) therapy has been widely used for the treatment of neurologic disorders, autoimmune diseases, immunodeficiency-related diseases, blood system diseases, and cancers. In this review, we summarize the efficacy and tolerability of IVIg and SCIg therapy in neurologic diseases.

METHODS

We summarized and analyzed the efficacy and tolerability of IVIg and SCIg in neurologic diseases, by analyzing the literature pertaining to the use of IVIg and SCIg to treat nervous system diseases.

FINDINGS

In clinical neurology practice, IVIg has been shown to be useful for the treatment of new-onset or recurrent immune diseases and for long-term maintenance treatment of chronic diseases. Moreover, IVIg may have applications in the management of intractable autoimmune epilepsy, paraneoplastic syndrome, autoimmune encephalitis, and neuromyelitis optica. SCIg is emerging as an alternative to IVIg treatment. Although SCIg has a composition similar to that of IVIg, the applications of this therapy are different. Notably, the bioavailability of SCIg is lower than that of IVIg, but the homeostasis level is more stable. Current studies have shown that these 2 therapies have pharmacodynamic equivalence.

IMPLICATIONS

In this review, we explored the efficacy of IVIg in the treatment of various neurologic disorders. IVIg administration still faces many challenges. Thus, it will be necessary to standardize the use of IVIg in the clinical setting. SCIg administration is a novel and feasible treatment option for neurologic and immune-related diseases, such as chronic inflammatory demyelinating polyradiculoneuropathy and idiopathic inflammatory myopathies. As our understanding of the mechanisms of action of IVIg improve, potential next-generation biologics can being developed.

Current proposed mechanisms of action of intravenous immunoglobulins in inflammatory neuropathies

Intravenous immunoglobulins (IVIg) have been shown in a number of trials, to be an effective treatment for the three main types of inflammatory neuropathies: Guillain-Barré Syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), and multifocal motor neuropathy (MMN). IVIg is thought to exert its immunomodulatory effects by affecting several components of the immune system including B-cells, T-cells, macrophages, complement, cytokines and cellular adhesion molecules. This article reviews the published evidence and the principal postulated mechanisms of action of intravenous immunoglobulins with special emphasis on inflammatory neuropathies.

Basic principles of intravenous immunoglobulin (IVIg) treatment

The original rationale for the therapeutic application of immunoglobulins was prevention and treatment of infectious diseases. With the description of agammaglobulinemia, substitution therapy became the primary indication for the use of immunoglobulins. Limitations and side effects of the intramuscular administration of immunoglobulins led to the development of preparations for intravenous use (IVIg). In the early 1980s an immunomodulatory effect of IVIg was described. Since then, the efficacy of IVIg has been established in controlled trials for diseases like idiopathic thrombocytopenic purpura, Kawasaki disease, Guillain-Barré syndrome, dermatomyositis, and many others. There is a large body of evidence that IVIg can modulate an immune reaction at the level of T cells, B cells, and macrophages, interferes with antibody production and degradation, modulates the complement cascade, and has effects on the cytokine network. However, the precise mechanism of action is not yet clear.

Acute anuric renal failure secondary to intravenous immunoglobulin in diabetic nephropathy

We present a case of acute renal failure in a diabetic patient who received intravenous immunoglobulin therapy. Vigam liquid immunoglobulin was used successfully to treat vancomycin induced toxic epidermal necrolysis, but 4 days later the patient became anuric. Renal function was restored after haemofiltration. Immunoglobulin therapy is used to treat immune-mediated conditions, many of which affect the diabetic population. Renal failure is a rare side effect of immunoglobulin in patients with diabetes and impaired renal function, of which many clinicians are unaware. Caution must be exercised in such patients and the risks of immunoglobulin treatment weighed against the benefits.

Pharmacokinetic effects of 4C9, an anti-FcRn antibody, in rats: implications for the use of FcRn inhibitors for the treatment of humoral autoimmune and alloimmune conditions

FcRn protects immune gamma globulin (IgG) from intracellular catabolism, and thereby contributes to the long plasma half-life associated with this class of antibody. The present study tested the hypothesis that 4C9, an anti-FcRn antibody, would increase the in vivo systemic clearance of a model antibody, anti-methotrexate IgG (AMI), in rats. Hybridomas secreting 4C9 and AMI were grown in serum free medium, and monoclonal 4C9 and AMI were purified via protein-G chromatography. Rats were instrumented with jugular vein cannulas 2-3 days prior to investigation, and 4C9 was administered intravenously at doses of 3, 15, and 60 mg/kg. AMI was then administered 4, 24, and 48 h after administration of 4C9. Blood samples were collected and assayed to determine AMI concentrations. The anti-FcRn antibody, 4C9, increased AMI systemic clearance in a dose-dependent manner (from 0.99+/-0.14 mg/h/kg in control animals to 1.27+/-0.05, 1.73+/-0.50, and 1.97+/-0.49 mL/h/kg in animals treated with 3, 15, and 60 mg/kg 4C9; p<0.05). These data were well-captured with an indirect-effect pharmacokinetic-pharmacodynamic model. The effect of 4C9 was found to be transient; no significant effects on AMI systemic clearance were observed when pre-treatment time was increased to 24 or 48 h. As such, the data demonstrate that 4C9, a monoclonal anti-FcRn antibody, induces a transient, dose-dependent increase in the elimination of IgG. The results suggest that FcRn inhibitors may have utility in the treatment of antibody-mediated autoimmune and alloimmune conditions.

Intravenous immunoglobulin in the preparation of thymectomy for myasthenia gravis

OBJECTIVES

A clinical trial including six patients was conducted to assess the effect of intravenous immunoglobulin (IVIg) in the preparation of thymectomy for patients with myasthenia gravis (MG).

MATERIAL AND METHODS

Six consecutive patients of type IIB MG treated with IVIg at a dose 0.4 g/kg daily for 5 days before thymectomy were enrolled in this study.

RESULTS

All patients responded positively to this treatment. Improvement began to occur 1-9 days after starting the injection (mean 3.33 days), and reached a maximum in 3-19 days (mean 6.50 days). Thymectomy was performed 9-13 days (mean 11.20 days) after starting the injection in five of the six patients with uneventful post-operative courses.

CONCLUSION

IVIg might be an alternative to plasmapheresis (PE) in the prethymectomy preparation of MG patients, and thymectomy should be performed within 2 weeks after IVIg treatment to minimize the perioperative complications. Controlled trial vs PE enrolling more patients is needed to assess the significance of the IVIg in the preparation of thymectomy for patients of MG.

Intravenous immunoglobulin in neurological disease: a specialist review

Treatment of neurological disorders with intravenous immunoglobulin (IVIg) is an increasing feature of our practice for an expanding range of indications. For some there is evidence of benefit from randomised controlled trials, whereas for others evidence is anecdotal. The relative rarity of some of the disorders means that good randomised control trials will be difficult to deliver. Meanwhile, the treatment is costly and pressure to "do something" in often distressing disorders considerable. This review follows a 1 day meeting of the authors in November 2000 and examines current evidence for the use of IVIg in neurological conditions and comments on mechanisms of action, delivery, safety and tolerability, and health economic issues. Evidence of efficacy has been classified into levels for healthcare interventions (tables 1 and 2).

Immunoglobulin treatment in refractory Myasthenia gravis

Failure to induce and maintain remission in severe exacerbations of myasthenia gravis (MG), despite optimal care, is a common problem. We evaluated the efficacy and safety of high-dose intravenous immunoglobulin (IVIg) therapy in an open-label study of 10 patients with severe generalized myasthenia and an acute deterioration unresponsive to conventional therapy including high-dose corticosteroids, cyclosporine, and azathioprine. Intravenous Ig at a loading dose of 400 mg/kg was administered daily for 5 consecutive days, with maintenance IVIg treatment at a dose of 400 mg/kg, once every 6 weeks. Significant improvement occurred in all patients, beginning at 6 +/- 2 days of treatment as measured by the Osserman scale, fatigue variables, muscle strength, and respiratory function tests. No side effects were observed during induction of remission. Further IVIg treatments were highly efficacious in maintaining the remission. The severity of the disease decreased by 2.5 +/- 0.8 grades of the Osserman scale over a period of 1 year (P <0.001), in parallel with reduction of immunosuppressive therapy as well as a decrease in acetylcholine receptor antibody titers (P < 0.01). Intravenous Ig therapy seems to be highly potent for inducing rapid improvement in refractory myasthenia during acute deterioration as well as for maintaining remission.

Intravenous immunoglobulin in the treatment of autoimmune neuromuscular diseases: present status and practical therapeutic guidelines

This review summarizes the current status of intravenous immunoglobulin (IVIg) in the treatment of autoimmune neuromuscular disorders and the possible mechanisms of action of the drug based on work in vivo, in vitro, and in animal models. Supply of idiotypic antibodies, suppression of antibody production, or acceleration of catabolism of immunoglobulin G (IgG) are relevant in explaining the efficacy of IVIg in myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS), and antibody-mediated neuropathies. Suppression of pathogenic cytokines has putative relevance in inflammatory myopathies and demyelinating neuropathies. Inhibition of complement binding and prevention of membranolytic attack complex (MAC) formation are relevant in dermatomyositis (DM), Guillain-Barré syndrome (GBS), and MG. Modulation of Fc receptors or T-cell function is relevant in chronic inflammatory demyelinating polyneuropathy (CIDP), GBS, and inflammatory myopathies. The clinical efficacy of IVIg, based on controlled clinical trials conducted in patients with GBS, CIDP, multifocal motor neuropathy (MMN), DM, MG, LEMS, paraproteinemic IgM anti-myelin-associated glycoprotein (anti-MAG) demyelinating polyneuropathies, and inclusion body myositis is summarized and practical issues related to each disorder are addressed. The present role of IVIg therapy in other disorders based on small controlled or uncontrolled trials is also summarized. Finally, safety issues, risk factors, adverse reactions, spurious results or serological tests, and practical guidelines associated with the administration of IVIg in the treatment of neuromuscular disorders are presented.

High-dose intravenous immunoglobulin in transient neonatal myasthenia gravis

A preterm newborn had transient neonatal myasthenia gravis and was mechanically ventilated for 9 days. In addition to the usual supportive care, she was treated with neostigmine and underwent two exchange transfusions. High-dose intravenous immunoglobulin therapy (2 gm/kg) was used for the first time in transient neonatal myasthenia gravis to the best of our knowledge. The clinical and laboratory responses are presented.

Randomised placebo-controlled trial of monthly intravenous immunoglobulin therapy in relapsing-remitting multiple sclerosis. Austrian Immunoglobulin in Multiple Sclerosis Study Group

BACKGROUND

Multiple sclerosis is an autoimmune disorder characterised by the repeated occurrence of demyelinating lesions within the central nervous system. Uncontrolled studies and experimental evidence suggest beneficial effects of repeated administration of intravenous immunoglobulin (IVIg) by immunomodulating mechanisms and induction or remyelination. We aimed to investigate the efficacy of IVIg in a randomised double-blind multicentre study.

METHODS

Patients with relapsing-remitting multiple sclerosis were randomly assigned a monthly dose of IVIg (0.15-0.2 g/kg bodyweight) or placebo. Duration of treatment was 2 years. The primary outcome measures were the effect of treatment on clinical disability-measured by the absolute change in Kurtzke's expanded disability status scale (EDSS) score- and the proportion of patients with improved, stable, or worse clinical disability (> or = 1.0 grade on EDSS score).

FINDINGS

Of the 243 patients screened, 150 met our eligibility criteria and were randomly assigned to IVIg or placebo. Before the start of treatment two patients in the placebo group dropped out, so there were 75 patients in the IVIg group and 73 in the placebo group. Intention-to-treat analysis showed that IVIg treatment had a beneficial effect on the course of clinical disability. The EDSS score decreased in the IVIg-treated patients and increased in the placebo group (-0.23 [95% CI -0.43 to -0.03] vs 0.12 [-0.13 to 0.37], p = 0.008). In the IVIg group, the numbers of patients with improved, stable, or worse clinical disability were 23 (31%), 40 (53%), and 12 (16%) compared with ten (14%), 46 (63%), and 17 (23%) in the placebo group. Side-effects were reported in three (4%) IVIg-treated patients and in four (5%) placebo-group patients, but were not directly linked to study medication.

INTERPRETATION

Monthly IVIg is an effective and well-tolerated treatment for patients with relapsing-remitting multiple sclerosis.

Ocular myasthenia: a protean disorder

Ocular myasthenia is a localized form of myasthenia clinically involving only the extraocular, levator palpebrae superioris, and/or orbicularis oculi muscles. Ocular manifestations can masquerade as a variety of ocular motility disorders, including cranial nerve and gaze palsies. A history of variable and fatiguable muscle weakness suggests this diagnosis, which may be confirmed by the edrophonium (Tensilon) test and acetylcholine receptor antibody titer. Anticholinesterases, corticosteroids and other immunosuppressive agents, and other therapeutic modalities, including thymectomy and plasmapheresis, are used in treatment. As the pathophysiology of myasthenia has been elucidated in recent years, newer treatment strategies have evolved, resulting in a much more favorable prognosis than several decades ago. This review provides historical background, pathophysiology, immuno-genetics, diagnostic testing, and treatment options for ocular myasthenia, as well as a discussion of drug-induced myasthenic syndromes.

Plasma exchange and intravenous immunoglobulin treatment of neuromuscular disease

Removal of immunoglobulin by plasma exchange and administration of immunoglobulin by intravenous infusion each improve selected neuromuscular diseases. Both treatments are expensive and relatively brief in their duration of action, but they benefit both self-limited neuromuscular diseases such as the Guillain-Barré syndrome and acute exacerbations of more chronic neuromuscular diseases including myasthenia gravis and chronic inflammatory demyelinating polyneuropathy. It is likely that plasma exchange acts by removing pathogenic antibodies. The mechanism by which intravenous immunoglobulin acts is less clear. Possibilities include (1) antiidiotypic antibody effect, (2) complement absorption, (3) downregulation of immunoglobulin production, (4) receptor blockade, (5) virus neutralization, (6) enhancement of suppressor cells, and (7) inhibition of lymphocyte proliferation. Although plasma exchange and intravenous immunoglobulin have major side effects, severe reactions are uncommon with plasma exchange and rare with intravenous immunoglobulin. Because of their low incidence of life-threatening complications, both treatments have major appeal to clinicians. Because of their brief action and high cost as well as the uncertainty as to whether either or both should be employed, their role in the therapeutic armamentarium of the neurologist requires further study.

The influence of intravenous immunoglobulin treatment on maternal immunity in women with unexplained recurrent miscarriage

PROBLEM

Recently the protective value of high-dose intravenous immunoglobulin (IVIG) in the treatment of unexplained recurrent miscarriage has been reported to be similar to that of conventional immunotherapy with paternal leukocytes. We examined the effect of IVIG treatment on the cellular and humoral level of maternal immunity to demonstrate the possible mechanism by which IVIG might act to prevent recurrence of pregnancy loss.

METHOD

Eight patients were treated with a 20- to 25-g dose of IVIG every 2 to 3 wk during their first-trimester pregnancies. The development of anti-idiotypic autoantibodies against maternal T-cell receptors, maternal anti-paternal lymphocyte antibodies detected by flow cytometric crossmatch, and changes of maternal lymphocyte subpopulations were monitored before pregnancy and then weekly during IVIG treatment.

RESULTS

Five of eight patients gave birth successfully after IVIG treatment given during the first trimester of pregnancy (success rate: 62.5%). Although we could not demonstrate a general immunological effect of IVIG on maternal immunity in vivo, a few significant changes of immunological parameters were found in some patients.

CONCLUSION

Our results suggest that the effect of IVIG on maternal immunity is not a passive increase of blocking antibody including anti-HLA antibody or modification of maternal T-cell subsets but, more likely, a passive increase of anti-idiotypic antibody against anti-HLA antibody or soluble HLA antigens. However, whether the immunomodulating effect of IVIG is related to its possible mechanism to prevent abortion remains unestablished.

High-dose intravenous immunoglobulin in myasthenia gravis

The effects of high-dose intravenous immunoglobulin (i.v.Ig) in 12 MG patients were studied. All patients had severe symptoms. In two cases anti-acetylcholine receptor antibodies (anti-AChR abs) were not detectable. I.v.Ig was administered to 9 patients already on long-term immunosuppressive therapy and to 3 patients at the beginning of azathioprine treatment. 10 patients (83%) improved; the duration of improvement was longer in immunosuppressed patients. Anti-AChR abs generally decreased after infusion but we did not find a constant correlation between reduction in ab titers and clinical improvement. Side effects included one case of severe hemolysis. In our experience i.v.Ig therapy is effective in MG. The chief indication for its use appears to be the treatment of deterioration of the disease in patients already on immunosuppressive therapy.

Treatment of myasthenia gravis with high-dose intravenous immunoglobulin

We treated 37 patients affected by autoimmune generalized myasthenia gravis (MG) with high-dose intravenous gammaglobulin (HDIVIg), 400 mg/kg per day on 5 consecutive days. A one-degree improvement of Oosterhuis global clinical classification of myasthenic severity (OGCCMS), the disappearance of bulbar involvement or both were recorded 12 days after the beginning of the treatment in 70.3% of the patients and persisted up to 60 days in 58.7%. A two-degree improvement of OGCCMS was recorded in 54.1% of the patients and it was maintained up to 60 days in 37.8%. The percentage of improvement did not significantly differ between patients entering the treatment in a long-standing, drug-refractory stationary phase of the illness (n = 26) and patients who received HDIVIg in an acute phase of MG (n = 11). None of the patients experienced side effects. Our data indicates that HDIVIg is an interesting, virtually riskless therapeutic choice for MG patients, and allows the planning of a controlled trial versus plasma-exchange.

Intravenous immunoglobulin (IVIG) for the therapy of autoimmune disorders

The weight of evidence from numerous clinical studies supports the use of IVIG, particularly at higher doses, in the treatment of a wide range of autoimmune disorders. Extensive experience has documented the safety of IVIG therapy but its present relatively high cost necessitates firmly establishing its efficacy. There is an acute need to define those disease states where IVIG is indicated and effective. Large-scale, possibly multicentered, clinical trials employing rigorous controls will resolve these questions. Concurrent fundamental immunologic studies will elucidate the mechanisms underlying the clinical effects. We are experiencing an exciting new era of effective immunotherapies and intravenous gamma-globulin preparations have already secured an important place in the therapeutic armamentarium. While one must guard against unsubstantiated applications, critical exploration of new uses for this unique product is warranted.

Experience with intravenous immunoglobulin in myasthenia gravis

Myasthenia gravis (MG) is an acquired autoimmune disorder of neuromuscular transmission associated with a deficiency of acetylcholine receptor at the neuromuscular junction. Current therapeutic strategies are aimed at increasing the amount of acetylcholine at the neuromuscular junction or at addressing the abnormal immune response. Therapies influencing the immune response include thymectomy, corticosteroids, nonsteroidal immunosuppression, and plasmapheresis. Unfortunately, whether used alone or in combination the toxicities of these agents can be quite significant; thus, an agent with a distinct and more favorable side effect profile might be useful in MG. Intravenous immunoglobulin has such potential.

Plasma C3c changes in myasthenia gravis patients receiving high-dose intravenous immunoglobulin during crisis

Fast-migrating C3c, a sensitive index of complement activation, was assayed in the plasma of 2 myasthenia gravis (MG) patients in crisis who received high-dose IV immunoglobulin therapy. Dramatic responses were observed in both patients. Clinical improvement paralleled a decrement in C3c levels, suggesting that regulation of complement activation may be one possible mechanism of IV immunoglobulin treatment in MG.

Effects of repeated doses of intravenous immunoglobulin in myasthenia gravis

The authors administered repeated courses of intravenous immunoglobulin (IVIg) to nine patients at the onset of an exacerbation of generalized myasthenia gravis (MG). Anticholinesterase medication (nine patients) and corticosteroid dosage (six patients) had been kept constant for a 2-month period. Six patients received two courses, two patients received three courses, and one patient received five courses. Twenty of 23 courses resulted in satisfactory improvement beginning 4.3 +/- 1.2 days after start of IVIg and becoming maximal 8.2 +/- 2.0 days, with sustained improvement lasting 106.6 +/- 49.1 days. Vital capacity increased from an average of 1845.1 +/- 489 cc to 2894 +/- 762 cc (p less than 0.01) at peak effect. Four of nine patients had a decrease in strength before improvement. There was no significant change in acetylcholine receptor antibody titers before or after therapy. Side effects were minimal. Of the three patients who had nonsatisfactory course, two responded well to additional IVIg. IVIg can produce repeated beneficial effects in patients with MG and may be useful as an adjunct in the management of MG.

Immediate effects of intravenous IgG administration on peripheral blood B and T cells and polymorphonuclear cells in patients with myasthenia gravis

Five patients with myasthenia gravis, who received treatment with intravenous 7S gamma-globulin were monitored for changes in immunological status. Serum immunoglobulin G increased from an average of 1.4 to 4.7 g/dl during the 5-day course of therapy. Specific antibody to the acetylcholine receptor present in three of five patients did not change. A transient decrease in total peripheral blood leukocytes was observed in five patients due to decreases in the absolute number of polymorphonuclear cells and lymphocytes in the circulation. Lymphocyte surface marker studies revealed that the percentage of surface immunoglobulin positive cells increased in all patients from an average of 13 to 26% by day 5 of therapy; however, the percentage of HLA-Dr- and Leu 12 (CD19)-positive B cells did not change. Lymphoid cells positive for the Leu 11 (CD16) marker doubled from an average of 11 to 24% during the 5-day course of therapy. Surface Ig-positive cells and Leu 11 (CD16)-positive cells returned to pretreatment values by 7 days posttherapy. Helper/suppressor cell ratios slowly decreased in all patients from an average of 2.9 to 2.2 by 1 week posttherapy and remained low for several weeks.

Intravenous immune globulin: dosage and administration

Intravenous immune globulin (IV-IgG) is approved for use in substitution therapy of immunodeficiency syndromes and treatment of idiopathic thrombocytopenic purpura (ITP). The initial dose for substitution therapy is 0.2 g/kg body weight repeated monthly. If necessary, the dose may be increased to 0.3 g/kg and the frequency to every 2-3 weeks. The approved dosage for ITP is 0.4 g/kg daily for 2 to 5 consecutive days. Repeat doses of 0.4 g/kg have been used as maintenance therapy. The initial infusions of IgG to immunodeficient patients who have not been treated during the previous 8 weeks or never treated at all should proceed with caution. These patients are at risk of potentially serious complement-mediated adverse reactions. Adverse reactions due to IgG administration are less frequent and less severe for patients with ITP. Currently available preparations are contraindicated in patients with a selective IgA deficiency and detectable IgA antibodies.

Complete recovery of pure red cell aplasia by intramuscular gammaglobulin therapy in a child with hypoparathyroidism

A 10-year-old girl with multiple endocrinopathies, hypoparathyroidism, and pernicious anemia subsequently developed pure red cell aplasia, which responded only temporarily to cytotoxic therapy. Because of transfusion dependency, resistance to steroids, plasmapheresis, and Cytoxan, she was given injections of intramuscular gammaglobulin. The injections caused a prompt and sustained rise in the child's erythropoiesis.