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Ouyang S, Wu X, Zhan Q, Wu F, Tan H, Duan W, Zeng Q, Gu W, Lu W, Yin W. Unique association of anti-GABA A receptor encephalitis and myasthenia gravis in a patient with type A thymoma. Neurol Sci 2024; 45:2203-2209. [PMID: 38051411 DOI: 10.1007/s10072-023-07239-0] [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: 08/02/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023]
Abstract
Association between anti-GABAAR encephalitis and myasthenia gravis is extremely rare with few reported cases. Herein, we report a case of a female patient diagnosed with anti-GABAAR encephalitis and thymoma at the first admission. She was administered glucocorticoids for long-term immunotherapy, and thymectomy with biopsy demonstrated a type A thymoma. After 4 months, the symptoms of encephalitis were relieved, but she then developed post-thymectomy myasthenia gravis with anti-AChR and anti-titin dual positivity. Antibodies to connective tissue (anti-ANA, anti-PCNA) and those characteristics of paraneoplastic syndrome (anti-Ma2/Ta) were also positive. She received oral glucocorticoids and tacrolimus as immunosuppressive therapy, and myasthenic symptoms were stable during a 2-year follow-up. Our case revealed that anti-GABAAR encephalitis and myasthenia gravis can appear in patient with type A thymoma at different periods, which alerts physicians to take long-term follow-up for anti-GABAAR encephalitis with thymoma, even after thymectomy. Concurrent positivity for more than one antibody after thymectomy is rarely observed, and their contribution to the clinical course and treatment decision remains to be further investigated.
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Affiliation(s)
- Song Ouyang
- Department of Neurology, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, People's Republic of China
- The "Double-First Class" Application Characteristic Discipline of Hunan Province (Clinical Medicine), Changsha Medical University, Changsha, Hunan, People's Republic of China
| | - Xiaomei Wu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People's Republic of China
| | - Qiong Zhan
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People's Republic of China
| | - Feng Wu
- Department of Pathology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Hong Tan
- Department of Neurology, The Affiliated Changsha Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, People's Republic of China
| | - Weiwei Duan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Qiuming Zeng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Wenping Gu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Wei Lu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People's Republic of China
| | - Weifan Yin
- The "Double-First Class" Application Characteristic Discipline of Hunan Province (Clinical Medicine), Changsha Medical University, Changsha, Hunan, People's Republic of China.
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, People's Republic of China.
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2
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Mehnert A, Bershan S, Kollmus-Heege J, Gerischer L, Herdick ML, Hoffmann S, Lehnerer S, Scheibe F, Stascheit F, Stein M, Buchan AM, Meisel A, Aigner A, Mergenthaler P. Identifying patients at risk for myasthenic crisis with hemogram and inflammation-related laboratory parameters - a pilot study. Front Neurol 2024; 15:1297997. [PMID: 38469587 PMCID: PMC10925644 DOI: 10.3389/fneur.2024.1297997] [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] [Received: 09/20/2023] [Accepted: 01/29/2024] [Indexed: 03/13/2024] Open
Abstract
Background Myasthenia gravis (MG) is a rare autoimmune disease characterized by fatigable weakness of the voluntary muscles and can exacerbate to life-threatening myasthenic crisis (MC), requiring intensive care treatment. Routine laboratory parameters are a cost-effective and widely available method for estimating the clinical outcomes of several diseases, but so far, such parameters have not been established to detect disease progression in MG. Methods We conducted a retrospective analysis of selected laboratory parameters related to inflammation and hemogram for MG patients with MC compared to MG patients without MC. To identify potential risk factors for MC, we applied time-varying Cox regression for time to MC and, as a sensitivity analysis, generalized estimating equations logistic regression for the occurrence of MC at the next patient visit. Results 15 of the 58 examined MG patients suffered at least one MC. There was no notable difference in the occurrence of MC by antibody status or sex. Both regression models showed that higher counts of basophils (per 0.01 unit increase: HR = 1.32, 95% CI = 1.02-1.70), neutrophils (per 1 unit increase: HR = 1.40, 95% CI = 1.14-1.72), potentially leukocytes (per 1 unit increase: HR = 1.15, 95% CI = 0.99-1.34), and platelets (per 100 units increase: HR = 1.54, 95% CI = 0.99-2.38) may indicate increased risk for a myasthenic crisis. Conclusion This pilot study provides proof of the concept that increased counts of basophils, neutrophils, leukocytes, and platelets may be associated with a higher risk of developing MC in patients with MG.
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Affiliation(s)
- Anne Mehnert
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Sivan Bershan
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Jil Kollmus-Heege
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Lea Gerischer
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Meret Luise Herdick
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Sarah Hoffmann
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Sophie Lehnerer
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
- Berlin Institute of Health at Charité, Digital Health Center, Berlin, Germany
| | - Franziska Scheibe
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Frauke Stascheit
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Maike Stein
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Alastair M. Buchan
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Annette Aigner
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Philipp Mergenthaler
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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3
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Nes MS, Haugen M, Haugland HK, Gilhus NE, Vedeler CA. Case report: Seropositive myasthenia gravis complicated by limbic encephalitis positive for antibodies to AMPAR and Lgi1. Front Neurol 2023; 14:1237140. [PMID: 37900608 PMCID: PMC10602774 DOI: 10.3389/fneur.2023.1237140] [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] [Received: 06/08/2023] [Accepted: 09/15/2023] [Indexed: 10/31/2023] Open
Abstract
Objectives Autoantibodies to the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) and leucine-rich glioma-inactivated 1 (Lgi1) are associated with autoimmune encephalitis. We described an acetylcholine receptor (AChR)-positive patient with myasthenia gravis who developed limbic encephalitis with antibodies to AMPAR and Lgi1. Methods A single-case report with detailed, prospective clinical and biomarker data including serial laboratory testing and histopathology. Results A 49-year-old woman was diagnosed with anti-AChR antibody-positive generalized myasthenia gravis in 1983. After 9 months of the removal of thymoma in 1984, she developed influenza-like symptoms and then symptoms of limbic encephalitis. Retrospective analysis of serum showed high concentrations of anti-AMPAR and lower concentrations of anti-Lgi1 antibodies. Cerebral CT was normal, EEG showed bifrontal dysrhythmia, and CSF showed mild pleocytosis. Immuno-histochemical examination of the thymoma confirmed staining for Glur2, a subunit of AMPAR. The patient recovered with mild sequelae, but low levels of anti-AMPAR and anti-Lgi1 antibodies were detectable for over 25 years subsequently. Discussion This case confirms earlier reports of AMPAR-associated autoimmune encephalitis co-occurring with thymoma and myasthenia gravis and is unique in its observational length. It shows, moreover, that antibodies to AMPAR and Lgi1 can persist despite clinical recovery.
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Affiliation(s)
- Magne Solberg Nes
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Mette Haugen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Alexander Vedeler
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Ozyurt Kose S, Nazli E, Tutkavul K, Gilhus NE. Occurrence and severity of myasthenic crisis in an unselected Turkish cohort of patients with myasthenia gravis. Front Neurol 2023; 14:1201451. [PMID: 37521306 PMCID: PMC10374359 DOI: 10.3389/fneur.2023.1201451] [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: 04/06/2023] [Accepted: 06/19/2023] [Indexed: 08/01/2023] Open
Abstract
Myasthenia gravis (MG) is a disorder of the neuromuscular junction that can deteriorate into myasthenic crisis, involving weakness of bulbar and respiratory muscles. In this study, we describe the clinical manifestations of myasthenic crisis, identify risk factors, and examine treatments and outcomes. All 95 patients with generalized MG treated at our center during the last 10 years were included in this retrospective study. We collected data from the patients' records, including clinical follow-ups, muscle antibodies, thymic status, and treatments. The characteristics of patients who did and did not experience myasthenic crisis were compared. Features of all myasthenic crises were also assessed. Twelve patients (13%) developed myasthenic crisis during the observation period. Men were more often affected at older ages. Seven patients experienced multiple myasthenic crises. Thymoma increased the risk of a crisis, whereas thymic hyperplasia decreased the risk. Myasthenic crises were more common in the summer months. No patients died during a myasthenic crisis. Risk factors for myasthenic crisis were thymoma, older age, MuSK antibodies, and previous crises. Individualized and active immunosuppressive treatment and optimal intensive care during crises provide a good outcome for patients with generalized MG.
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Affiliation(s)
- Selen Ozyurt Kose
- Department of Clinical Neurophysiology, Marmara University Pendik Teaching and Research Hospital, Istanbul, Turkey
| | - Ezgi Nazli
- Department of Neurology, Health Sciences University Haydarpasa Numune Teaching and Research Hospital, Istanbul, Turkey
| | - Kemal Tutkavul
- Department of Neurology, Health Sciences University Haydarpasa Numune Teaching and Research Hospital, Istanbul, Turkey
| | - Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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5
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Claytor B, Cho SM, Li Y. Myasthenic crisis. Muscle Nerve 2023. [PMID: 37114503 DOI: 10.1002/mus.27832] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/06/2023] [Accepted: 04/09/2023] [Indexed: 04/29/2023]
Abstract
Myasthenic crisis (MC) is a life-threatening manifestation of myasthenia gravis (MG) defined by respiratory insufficiency that requires the use of invasive or non-invasive ventilation. This is often the result of respiratory muscle weakness but can also be due to bulbar weakness with upper airway collapse. MC occurs in approximately 15%-20% of patients with MG usually within the first 2 to 3 y of the disease course. Many crises have a specific trigger with respiratory infections being most common; however, no specific trigger is found in 30%-40% of patients. MG patients with a history of MC, severe disease, oropharyngeal weakness, muscle-specific kinase (MuSK) antibodies and thymoma appear to be at higher risk. Most episodes of MC do not occur suddenly, providing a window of opportunity for prevention. Immediate treatment is directed toward airway management and removing any identified triggers. Plasmapheresis is preferred over intravenous immune globulin as the treatments of choice for MC. The majority of patients are able to be weaned from mechanical ventilation within 1 mo and the outcomes of MC are generally favorable. The mortality rate in United States cohorts is less than 5% and mortality in MC seems to be driven by age and other medical co-morbidities. MC does not appear to affect long-term prognosis as many patients are able to eventually achieve good MG control.
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Affiliation(s)
- Benjamin Claytor
- Neuromuscular Center, Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yuebing Li
- Neuromuscular Center, Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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6
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Chen K, Li Y, Yang H. Poor responses and adverse outcomes of myasthenia gravis after thymectomy: Predicting factors and immunological implications. J Autoimmun 2022; 132:102895. [PMID: 36041292 DOI: 10.1016/j.jaut.2022.102895] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
Abstract
Myasthenia gravis (MG) has been recognized as a series of heterogeneous but treatable autoimmune conditions. As one of the indispensable therapies, thymectomy can achieve favorable prognosis especially in early-onset generalized MG patients with seropositive acetylcholine receptor antibody. However, poor outcomes, including worsening or relapse of MG, postoperative myasthenic crisis and even post-thymectomy MG, are also observed in certain scenarios. The responses to thymectomy may be associated with the general characteristics of patients, disease conditions of MG, autoantibody profiles, native or ectopic thymic pathologies, surgical-related factors, pharmacotherapy and other adjuvant modalities, and the presence of comorbidities and complications. However, in addition to these variations among individuals, pathological remnants and the abnormal immunological milieu and responses potentially represent major mechanisms that underlie the detrimental neurological outcomes after thymectomy. We underscore these plausible risk factors and discuss the immunological implications therein, which may be conducive to better managing the indications for thymectomy, to avoiding modifiable risk factors of poor responses and adverse outcomes, and to developing post-thymectomy preventive and therapeutic strategies for MG.
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Affiliation(s)
- Kangzhi Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.
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7
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Zhuang J, Guan M, Liu M, Liu Y, Yang S, Hu Z, Lai F, He F. Immune-Related Molecular Profiling of Thymoma With Myasthenia Gravis. Front Genet 2021; 12:756493. [PMID: 34777476 PMCID: PMC8580862 DOI: 10.3389/fgene.2021.756493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/15/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Approximately 50% of thymoma patients also show myasthenia gravis (MG), which is an autoimmune disease; however, the pathogenesis of MG-associated thymoma remains elusive. Our aim was to investigate immune-related lncRNA profiles of a set of candidate genes for better understanding of the molecular mechanism underlying the pathogenesis of thymoma with or without MG. Methods: Molecular profiles of thymoma with or without MG were downloaded from The Cancer Genome Atlas, and Pearson's correlation analysis was performed to identify immune-related lncRNAs. T test was used to examine the differential expression and differential methylation between thymoma patients with or without MG. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses were performed to predict the function of target genes of immune-related lncRNAs. Results: Analyses of the 87 thymoma samples with complete MG information revealed that 205 mRNAs and 56 lncRNAs showed up-regulated expression in thymoma with MG patients, while 458 mRNAs and 84 lncRNAs showed down-regulated expression. The methylation level of three immune-related lncRNAs (AP000787.1, AC004943.1, WT1-AS, FOXG1-AS1) was significantly decreased in thymoma tissues, and the methylation level of these immune-related lncRNAs (WT1-AS: Cor = 0.368, p < 0.001; FOXG1-AS1: Cor = 0.288, p < 0.01; AC004943.1: Cor = -0.236, p < 0.05) correlated with their expression. GO and KEGG pathway analysis revealed that targets of the immune-related lncRNA FOXG1-AS1 were enriched in small GTPase binding and herpes simplex virus 1 infection. Transcription coregulator activity and cell cycle were the most enriched pathways for targets of lncRNA AC004943.1. LncRNA WT1-AS targets were most enriched in actin binding and axon guidance. Conclusion: Our results revealed the immune-related molecular profiling of thymoma with MG and without MG and identified key pathways involved in the underlying molecular mechanism of thymoma-related MG. These findings provide insights for further research of potential markers for thymoma-related MG.
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Affiliation(s)
- Jinman Zhuang
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China.,Fujian Digital Tumor Data Research Center, Fuzhou, China
| | - Maohao Guan
- Department of Thoracic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Maolin Liu
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China.,Fujian Digital Tumor Data Research Center, Fuzhou, China
| | - Yuhang Liu
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China.,Fujian Digital Tumor Data Research Center, Fuzhou, China
| | - Shuyan Yang
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China.,Fujian Digital Tumor Data Research Center, Fuzhou, China
| | - Zhijian Hu
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China.,Fujian Digital Tumor Data Research Center, Fuzhou, China
| | - Fancai Lai
- Department of Thoracic Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Fei He
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, China.,Fujian Provincial Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China.,Fujian Digital Tumor Data Research Center, Fuzhou, China
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8
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Zhang C, Bu B, Yang H, Wang L, Liu W, Duan RS, Zhang M, Zeng P, Du C, Yang L, Shi FD. Immunotherapy choice and maintenance for generalized myasthenia gravis in China. CNS Neurosci Ther 2020; 26:1241-1254. [PMID: 33103369 PMCID: PMC7702233 DOI: 10.1111/cns.13468] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022] Open
Abstract
Aims To compare long‐term efficacy and safety of immunotherapeutic strategies as maintenance to prevent disease relapses of generalized myasthenia gravis (MG) in real‐world settings. Methods This is a retrospective cohort study on generalized MG conducted in seven major neurological centers across China. Eligible participants were patients with generalized MG who were under minimal manifestation status or better. Main outcome measures were probability of patients free of relapses and causes of drug discontinuation. Results Among 1064 patients enrolled, the median (interquartile range) age was 50.3 (37.0‐62.5) years and 641 (60.2%) were women. Disease relapse was significantly lower for rituximab (6.1%) compared with all the other monotherapies (hazard ratio [HR] = 0.18, 95% confidence interval [CI] 0.06 to 0.56, P = .0030). As combination therapies, tacrolimus in combination with corticosteroids reduced risk of disease relapses compared with azathioprine with corticosteroids (HR = 0.45, 95% CI 0.25 to 0.81, P = .0077) or mycophenolate mofetil with corticosteroids (HR = 0.32, 95% CI 0.15 to 0.67, P = .0020). Otherwise, lower‐dose corticosteroids or azathioprine as monotherapy significantly increased risk of disease relapses (HR = 2.78, 95% CI 1.94 to 3.99, P < .0001; HR = 2.14, 95% CI 1.42 to 3.23, P = .0003, respectively). The proportion of discontinuation was lowest in patients with rituximab (20.4%) as monotherapy and tacrolimus with corticosteroids (23.6%). Overall, combination treatment of immunosuppressants with corticosteroids had a lower rate of discontinuation compared with corresponding monotherapy (HR = 0.51, 95% CI 0.36 to 0.71, P < .0001). Conclusions Rituximab as monotherapy and tacrolimus with corticosteroids displayed better clinical efficacy as well as drug maintenance to prevent disease relapses in patients with generalized MG.
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Affiliation(s)
- Chao Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.,National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Weibin Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rui-Sheng Duan
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Meini Zhang
- Department of Neurology, The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Pei Zeng
- National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chen Du
- National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Yang
- National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fu-Dong Shi
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.,National Clinical Research Center for Neurological Diseases of China, Jing-Jin Center for Neuroinflammation, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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9
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Liu C, Liu P, Zhang XJ, Li WQ, Qi G. Assessment of the risks of a myasthenic crisis after thymectomy in patients with myasthenia gravis: a systematic review and meta-analysis of 25 studies. J Cardiothorac Surg 2020; 15:270. [PMID: 32993739 PMCID: PMC7526111 DOI: 10.1186/s13019-020-01320-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/21/2020] [Indexed: 01/11/2023] Open
Abstract
Background Despite the burgeoning literature describing preoperative and postoperative risks of a myasthenic crisis after thymectomy (MCAT) in patients with myasthenia gravis, substantial differences exist in the risk factors identified by previous studies. We conducted a meta-analysis to assess the reported risk factors and MCAT risk. Methods We collected relevant studies on the risk factors for MCAT by searching the PubMed, Embase, The Cochrane Library, China Biology Medicine (CBM), WanFang Data, VIP and CNKI databases. The search period ranged from the establishment of the database to November 2019. Results Twenty-five of the 458 identified studies were eligible for the meta-analysis. Seven retrospective cohort studies and 18 case-control studies were included, and 14 risk factors for MCAT were extracted. Meta-analyses of the association between MCAT and risk factors related to the patient’s preoperative condition included a preoperative history of MC, preoperative bulbar symptoms, IIa + IIb + III + VI, IIb + III + VI, VI + V, dosage of pyridostigmine bromide prior to the operation, a preoperative AchR-Ab level > 100 (nm/L), preoperative pulmonary function, preoperative complications, and preoperative disease course. Meta-analyses of the association between MCAT and surgery-related risk factors included intraoperative blood loss > 1000 mL and the mode of operation. Meta-analyses of the association between MCAT and postoperative risk factors included postoperative lung infection, thymoma and the WHO classification. The operation time was not an independent risk factor for MCAT. Conclusions The independent risk factors for MCAT were a preoperative history of MC, preoperative bulbar symptoms, preoperative MG Osserman stage, preoperative dosage of pyridostigmine bromide, preoperative serum AchR-Ab level, lung function, major postoperative complications, disease duration before thymectomy, blood loss, thoracotomy, postoperative lung infection, thymoma, and WHO classification.
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Affiliation(s)
- Chaoying Liu
- Hebei Key Laboratory of Myasthenia Gravis, Center of Treatment of Myasthenia Gravis Hebei Province, First Hospital of Shijiazhuang, No. 9 Fangbei Road, Chang'an District, Shijiazhuang, 050011, Hebei Province, China
| | - Peng Liu
- Hebei Key Laboratory of Myasthenia Gravis, Center of Treatment of Myasthenia Gravis Hebei Province, First Hospital of Shijiazhuang, No. 9 Fangbei Road, Chang'an District, Shijiazhuang, 050011, Hebei Province, China
| | - Xiao Jing Zhang
- Hebei Key Laboratory of Myasthenia Gravis, Center of Treatment of Myasthenia Gravis Hebei Province, First Hospital of Shijiazhuang, No. 9 Fangbei Road, Chang'an District, Shijiazhuang, 050011, Hebei Province, China
| | - Wen Qian Li
- Hebei Key Laboratory of Myasthenia Gravis, Center of Treatment of Myasthenia Gravis Hebei Province, First Hospital of Shijiazhuang, No. 9 Fangbei Road, Chang'an District, Shijiazhuang, 050011, Hebei Province, China
| | - Guoyan Qi
- Hebei Key Laboratory of Myasthenia Gravis, Center of Treatment of Myasthenia Gravis Hebei Province, First Hospital of Shijiazhuang, No. 9 Fangbei Road, Chang'an District, Shijiazhuang, 050011, Hebei Province, China.
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Subramanian MP. Commentary: Thoughts on Thymectomy-When Myasthenia Is Made Worse. Semin Thorac Cardiovasc Surg 2019; 32:386-387. [PMID: 31783121 DOI: 10.1053/j.semtcvs.2019.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 11/15/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Melanie P Subramanian
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
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