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Wilson L, Davis H. The Role of Thymoma and Thymic Hyperplasia as Prognostic Risk Factors for Secondary Generalisation in Adults with Ocular Myasthenia Gravis: A Systematic Narrative Review. Br Ir Orthopt J 2023; 19:108-119. [PMID: 38046270 PMCID: PMC10691285 DOI: 10.22599/bioj.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/06/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose The conversion of ocular myasthenia gravis (OMG) to generalised myasthenia gravis (GMG) is reported to differ depending on the presence of generalisation risk factors (Mazzoli et al. 2018). Thymic pathology has been recognised as a potential risk factor for generalisation in the literature (Teo et al. 2017). Thymoma and thymic hyperplasia have yet to be examined as a risk factor for generalisation of OMG independently of other risk factors in the literature. Thus, the purpose of this review is to examine the literature to identify whether thymoma and thymic hyperplasia do increase the risk of OMG progressing to GMG. Methods A literature search was carried out which employed a systematic approach. The search was undertaken using the following academic libraries: MEDLINE, Embase and Starplus. The search was limited to publications between the years 2001 to 2021. The search yielded 82 studies, which after the screening of titles and abstracts, left 62 studies for further analysis against the inclusion and exclusion criteria. Results The review found thymoma to be associated with an increased risk of GMG development. However, there was a scarce amount of literature which investigated thymic hyperplasia. Therefore, a firm conclusion could not be made with regards to thymic hyperplasia and the risk of GMG development. Conclusions This review provides evidence for the consideration of thymectomy early after thymomatous OMG diagnosis to prevent GMG conversion. As the review did not collect enough evidence to support the influence of thymic hyperplasia on OMG conversion, further research is required.
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Affiliation(s)
| | - Helen Davis
- The medical school University of Sheffield, UK
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2
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Croitoru CG, Cuciureanu DI, Hodorog DN, Grosu C, Cianga P. Autoimmune myasthenia gravis and COVID-19. A case report-based review. J Int Med Res 2023; 51:3000605231191025. [PMID: 37565671 PMCID: PMC10422912 DOI: 10.1177/03000605231191025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/13/2023] [Indexed: 08/12/2023] Open
Abstract
A potential relationship between COVID-19 infection and new onset myasthenia gravis (MG) has been suggested by the coexistence of these two diseases in a number of reports. This study aimed to assess their relationship by reviewing case studies of COVID-19 followed by new onset MG published between 01 December 2019 and 30 June 2023 identified by a search of PubMed/Medline database. In addition, we reviewed evidence in favour and against a potential cause and effect association, and described possible mechanisms that would underpin such a relationship. We identified 14 publications that reported 18 cases. Analysis showed the following features: age 19-83 years; 10 men/8 women; median time interval between COVID-19 and MG (17, 5-56 days); autoimmune comorbidities (4); generalised MG (14); ocular MG (4); thymoma (3); antiacetylcholine receptor antibody (16); antimuscle-specific kinase antibodies (2). All patients improved following treatment. Proof of direct causality between the two conditions can only be established in time by confirming epidemiological increase in the incidence of MG or elucidating pathogenic mechanisms to substantiate a possible cause-effect association, or both.
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Affiliation(s)
- Cristina Georgiana Croitoru
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
- Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, Iași, Romania
| | - Dan Iulian Cuciureanu
- Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, Iași, Romania
- Department Medical III, Department of Neurology,” Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Diana Nicoleta Hodorog
- Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, Iași, Romania
- Department Medical III, Department of Neurology,” Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Cristina Grosu
- Department Medical III, Department of Neurology,” Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Petru Cianga
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
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3
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Narita T, Nakane S, Nagaishi A, Minami N, Niino M, Kawaguchi N, Murai H, Kira JI, Shimizu J, Iwasa K, Yoshikawa H, Hatanaka Y, Sonoo M, Shimizu Y, Matsuo H. Immunotherapy for ocular myasthenia gravis: an observational study in Japan. Ther Adv Neurol Disord 2023; 16:17562864231163819. [PMID: 37051222 PMCID: PMC10084546 DOI: 10.1177/17562864231163819] [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: 12/08/2022] [Accepted: 02/27/2023] [Indexed: 04/14/2023] Open
Abstract
Background Treatment for ocular myasthenia gravis (OMG) has not yet been well established. Few reports have been published on the clinical practice and outcomes of OMG. Objectives We investigated treatment of OMG and its outcomes in Japan.We investigated treatment of OMG and its outcomes in Japan. Design We performed a retrospective cross-sectional survey of OMG patients from eight hospitals in Japan. Methods Clinical information, including sex, age at onset, initial symptoms, autoantibodies, clinical course, treatment history, complications, and outcomes, was obtained. In addition, we recorded the total number of patients with MG and OMG separately. Results In total, 135 patients with OMG (67 men, 68 women) were included. Treatment of OMG was not simple and involved various immunotherapeutic strategies. Eight patients went into remission spontaneously without immunotherapy. A total of 117 patients showed improvements after treatment, whereas 10 patients showed refractory responses to treatment. Overall outcomes were good; however, symptoms persisted in 60.7% of patients even after treatment. Among 90 patients who received immunotherapy, only two showed a refractory response. Meanwhile, for 45 patients who did not receive immunotherapy, 8 were refractory. Thus, the rate of refractory disease in the group with immunotherapy was significantly lower (p = 0.001, u-test) than in the group without immunotherapy. The proportion of generalized MG patients among all MG cases was low in medical centers where immunotherapy for OMG was frequently performed. Conclusion Although the overall prognosis for patients with OMG was good, symptoms remained in more than half of the patients. Immunotherapy, including corticosteroids, may be beneficial for patients with OMG. Plain language summary Is immunosuppressive therapy beneficial for myasthenia gravis patients with ocular symptoms only? Patients with ocular myasthenia gravis (OMG) have only eye symptoms for more than 2 years. Whether this condition is an initial stage of the disease before eventually progressing to generalized myasthenia gravis (gMG) is still uncertain. Different from gMG, OMG is not life-threatening. But eye symptoms often cause troublesome problems in life. Doctors have treated OMG patients similarly to patients with gMG. There is no standard clinical practice for OMG. In this study, we examined how patients with OMG were treated at eight different specialist centers in Japan. In 135 patients with OMG, 8 patients became symptom free without treatment, 117 patients showed improvements after treatment, whereas 10 patients did not get well. Overall outcomes were good, but symptoms remained in 60.7% of patients even after treatment. Among 90 patients who received one or more immunotherapies, only 2 did not get well. Meanwhile, for 45 patients who did not receive immunotherapy, 8 remained ill. We found that treatment of OMG was not simple and often needed multiple immunotherapies. Administering immunotherapy, including corticosteroids, may be beneficial for patients with OMG.
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Affiliation(s)
| | | | - Akiko Nagaishi
- Department of Neurology, National Hospital Organization, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization, Hokkaido Medical Center, Sapporo, Japan
| | - Masaaki Niino
- Department of Neurology, National Hospital Organization, Hokkaido Medical Center, Sapporo, Japan
| | | | - Hiroyuki Murai
- Department of Neurology, Neurological Institute, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
- Department of Neurology, International University of Health and Welfare, Tokyo, Japan
| | - Jun-ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Jun Shimizu
- Department of Neurology, Tokyo University, Tokyo, Japan
| | - Kazuo Iwasa
- Department of Neurology and Neurobiology of Aging, Kanazawa University, Kanazawa, Japan
| | - Hiroaki Yoshikawa
- Department of Neurology and Neurobiology of Aging, Kanazawa University, Kanazawa, Japan
- Health Service Center, Kanazawa University, Kanazawa, Japan
| | - Yuki Hatanaka
- Department of Neurology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Masahiro Sonoo
- Department of Neurology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Yuko Shimizu
- Department of Neurology, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
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Treatment and Management of Disorders of the Neuromuscular Junction. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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5
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Jain R, Aulakh R. Pediatric Ocular Myasthenia Gravis: A Review. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1721401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractPediatric ocular myasthenia gravis (OMG) is difficult to diagnose and manage, owing to its rarity and low index of suspicion in the early stage of the disease. Also, many other conditions having similar presentation cause a further delay in diagnosis. In this review, we highlighted various pointers in history and described bedside clinical tests that can aid in its timely diagnosis. The antibody spectrum in myasthenia is ever increasing and includes anti-muscle specific kinase and low-density lipoprotein-receptor related protein 4 antibodies in addition to acetylcholine receptor antibodies besides many others. However, pediatric OMG patients often test negative for all three antibodies, making the diagnosis even more difficult in triple seronegative patients. Edrophonium and electrophysiological tests, which help in confirming myasthenia in adults, have a limited utility in diagnosing pediatric ocular myasthenia cases. Various practical difficulties are encountered like nonavailability of edrophonium, risk of bradycardia associated with neostigmine use and its lower sensitivity, noncooperative children, and limited technical expertise in performing electrophysiological tests in children. In this article, we described a pragmatic approach to diagnose pediatric OMG along with the important aspects of its management.
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Affiliation(s)
- Reena Jain
- Department of Pediatrics, Government Medical College & Hospital, Chandigarh, India
| | - Roosy Aulakh
- Department of Pediatrics, Government Medical College & Hospital, Chandigarh, India
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Saint-Gerons M, Rubio MA, Martinez A, Matheu A. Quantification of Cover Test Prior and Post Pyridostigmine in Diagnosis of Myasthenia Gravis. J Binocul Vis Ocul Motil 2021; 71:71-76. [PMID: 33877951 DOI: 10.1080/2576117x.2021.1904097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 06/12/2023]
Abstract
Objective: To assess the value of measuring diplopia before and after pyridostigmine intake to differentiate myasthenia gravis from sagging eye syndrome.To establish a threshold for a positive response to pyridostigmine in the diagnosis of myasthenia gravis.Methods: 15 patients with myasthenia gravis and 15 with sagging eye syndrome diplopia were evaluated. Diplopia was measured in five positions (upgaze, downgaze, right gaze, left gaze, and primary position). After baseline measurements, the patient received a single dose (60 mg) of pyridostigmine. After 60 minutes the prism measure was performed again in five positions. Horizontal deviation, vertical deviation at distance was compared before and after a single dose of pyridostigmine in each gaze. Ocular deviations were compared between the two groups to identify the threshold with the highest sensitivity and specificity.Results: Differences between pretest deviations and posttest deviations in any gaze were found to be statistically significant only in the MG group. The optimum threshold for a positive response to pyridostigmine was a reduction of 2 prism diopters in any component in any gaze. Sensitivity for the detection of myasthenia diplopia was 80.00% and specificity was 86.67%.Conclusions: Our results suggest that measuring diplopia with prisms before and after pyridostigmine administration can help to detect patients with suspected myasthenia.
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Affiliation(s)
- Marta Saint-Gerons
- Unit of Neurophthalmology, Consorci Parc de Salut MAR de Barcelona, Barcelona, Spain
- Department of Ophthalmology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Miguel Angel Rubio
- Unit of Neurophthalmology, Consorci Parc de Salut MAR de Barcelona, Barcelona, Spain
- Unit of Neuromuscular Diseases, Consorci Parc de Salut MAR de Barcelona, Barcelona, Spain
| | - Ana Martinez
- Department of Ophthalmology, Universitat Autònoma de Barcelona, Barcelona, Spain
- Ophthalmology, Consorci Parc de Salut MAR de Barcelona, Barcelona, Spain
| | - Ana Matheu
- Unit of Neurophthalmology, Consorci Parc de Salut MAR de Barcelona, Barcelona, Spain
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7
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Evoli A, Iorio R. Controversies in Ocular Myasthenia Gravis. Front Neurol 2020; 11:605902. [PMID: 33329368 PMCID: PMC7734350 DOI: 10.3389/fneur.2020.605902] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
Myasthenia gravis (MG) with symptoms limited to eye muscles [ocular MG (OMG)] is a rare disease. OMG incidence varies according to ethnicity and age of onset. In recent years, both an increase in incidence rate, particularly in the elderly, and a lower risk for secondary generalization may have contributed to the growing disease prevalence in Western countries. OMG should be considered in patients with painless ptosis and extrinsic ophthalmoparesis. Though asymmetric muscle involvement and symptom fluctuations are typical, in some cases, OMG can mimic isolated cranial nerve paresis, internuclear ophthalmoplegia, and conjugate gaze palsy. Diagnostic confirmation can be challenging in patients negative for anti-acetylcholine receptor and anti-muscle-specific tyrosine kinase antibodies on standard radioimmunoassay. Early treatment is aimed at relieving symptoms and at preventing disease progression to generalized MG. Despite the absence of high-level evidence, there is general agreement on the efficacy of steroids at low to moderate dosage; immunosuppressants are considered when steroid high maintenance doses are required. The role of thymectomy in non-thymoma patients is controversial. Prolonged exposure to immunosuppressive therapy has a negative impact on the health-related quality of life in a proportion of these patients. OMG is currently excluded from most of the treatments recently developed in generalized MG.
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Affiliation(s)
- Amelia Evoli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raffaele Iorio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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8
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Shi M, Ye Y, Zhou J, Qin A, Cheng J, Ren H. Local use of dexamethasone in the treatment of ocular myasthenia gravis. BMC Ophthalmol 2020; 20:432. [PMID: 33115419 PMCID: PMC7594471 DOI: 10.1186/s12886-020-01697-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 10/14/2020] [Indexed: 11/24/2022] Open
Abstract
Background At present, patients with ocular myasthenia gravis (OMG) are typically treated with systemic drugs. We investigated the use of dexamethasone injected in the peribulbar region or extraocular muscle to treat patients with OMG. Methods Patients with OMG were given dexamethasone via peribulbar injection or direct injection into the main paralyzed extraocular muscles, once a week, for 4–6 weeks. The severity of diplopia, blepharoptosis, eye position, and eye movement were evaluated before and after treatment. The duration of follow-up time was ≥6 months. Results Among the 14 patients with OMG who received this treatment, mean age was 38.7 ± 29.7 years. After treatment, symptoms were relieved in 12 patients (85.7%), 1 patient (7.1%) had partial response to treatment, and 1 patient (7.1%) had no response. Two patients (14.2%) experienced symptom recurrence during the follow-up period. Conclusions Dexamethasone peribulbar or extraocular muscle injection is effective in the treatment of patients with OMG and may replace systemic drug therapy. Trial registration Chinese Clinical Trial Registry, ChiCTR2000038863, October 7, 2020.Retrospectively registered. Supplementary information The online version contains supplementary material available at 10.1186/s12886-020-01697-2.
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Affiliation(s)
- Minghua Shi
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China.
| | - Yingjia Ye
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China
| | - Junping Zhou
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China
| | - Aijiao Qin
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China
| | - Jing Cheng
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China
| | - Hongxing Ren
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China
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9
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de Meel RHP, Raadsheer WF, van Zwet EW, Tannemaat MR, Verschuuren JJGM. Ocular Weakness in Myasthenia Gravis: Changes in Affected Muscles are a Distinct Clinical Feature. J Neuromuscul Dis 2019; 6:369-376. [PMID: 31424417 PMCID: PMC6839603 DOI: 10.3233/jnd-190407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Introduction: In this study we quantitatively describe ocular weakness patterns in myasthenia gravis (MG) to help neurologists in making the clinical diagnosis and to investigate how the current outcome measures reflect ocular weakness in MG. Methods: We investigated ptosis and diplopia patterns in a retro- and prospective cohort of 306 MG patients. Diplopia was systematically examined by testing extra-ocular muscle (EOM) fatigability in two horizontal and four oblique directions for 60 seconds. Results: Of patients with initial symmetric ptosis, 40% developed asymmetric ptosis at the second visit. Changes in form of ptosis occurred less often in seronegative MG patients (50%) than in patients with acetylcholine receptor (AChR) antibodies (70%) or muscle-specific kinase (MuSK) antibodies (69%) (p = 0.038). Of patients with diplopia on the first visit, double vision contained both a vertical and horizontal component in 95%. At the second visit, 83% manifested diplopia in other gaze directions. The mean time (in seconds) to diplopia was 11.6±14.0 and the mean time to ptosis was 27.6±19.8. Diplopia or ptosis manifested within 30 seconds in 87% and 58%, respectively. Patients who manifested diplopia after 30 seconds, reported no limitations due to diplopia. Discussion: Changes in the gaze directions in which diplopia occurs or ptosis side occur frequently in MG. In diagnostically challenging cases, we recommend testing ptosis and diplopia in multiple gaze directions for 30–60 seconds during at least two follow-up visits to maximize the chance of observing changes in ocular weakness patterns.
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Affiliation(s)
- Robert H P de Meel
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter F Raadsheer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik W van Zwet
- Department of Biostatistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
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11
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Ahn J, Park KS, Kim JS, Hwang JM. Efficacy of Gaze Photographs in Diagnosing Ocular Myasthenia Gravis. J Clin Neurol 2018; 14:333-338. [PMID: 29856158 PMCID: PMC6031998 DOI: 10.3988/jcn.2018.14.3.333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/20/2018] [Accepted: 02/20/2018] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose The various tests that are routinely used to diagnose generalized myasthenia gravis, such as the edrophonium test, serum anti-acetylcholine-receptor antibodies (AChR-Ab), and repetitive nerve stimulation (RNS) tests, have lower diagnostic sensitivity in ocular myasthenia gravis (OMG). Diagnosing OMG becomes even more difficult when the clinical symptoms are subtle. There is no gold-standard diagnostic test available for OMG patients, and so this study compared the diagnostic sensitivity of gaze photographs with conventional tests in OMG. Methods Records of gaze photographs were available for 25 of 31 consecutive patients diagnosed with OMG. Each patient underwent a neuro-ophthalmologic examination, serum AChR-Ab, RNS, edrophonium test, ice tests, and the acquisition of gaze photographs. The margin reflex distance 1 (MRD1) was measured on each of the gaze photographs, with MRD1 <2 mm or an interlid MRD1 difference of ≥2 mm on any of the gaze photographs defined as a positive sign of OMG. The diagnostic sensitivities of the tests were assessed. Results The mean age at onset was 38.5 years (range, 2–76 years), and 13 patients (52%) were men. The diagnostic sensitivities of the RNS test, AChR-Ab test, gaze photographs, and ice test were 56%, 64%, 80%, and 73%, respectively. Conclusions The diagnostic sensitivity was higher for gaze photographs than for the other tests applied to OMG patients.
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Affiliation(s)
- Jeeyun Ahn
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea.,Department of Ophthalmology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong Min Hwang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea.,Department of Ophthalmology, Seoul National University Bundang Hospital, Seongnam, Korea.
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13
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Abstract
PURPOSE OF REVIEW This article discusses the pathogenesis, diagnosis, and management of autoimmune myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS). RECENT FINDINGS Recognition of new antigenic targets and improved diagnostic methods promise to improve the diagnosis of MG, although the clinical phenotypes associated with newer antibodies have not yet been defined. Future therapies might specifically target the aberrant immune response. The apparent increase in the prevalence of MG is not fully explained. Results of a long-awaited trial of thymectomy support the practice of performing a thymectomy under specific conditions. SUMMARY The current treatment options are so effective in most patients with MG or LEMS that in patients with refractory disease the diagnosis should be reconsidered. The management of MG is individualized, and familiarity with mechanisms, adverse effects, and strategies to manage these commonly used treatments improves outcome. Patient education is important. LEMS, frequently associated with an underlying small cell lung cancer, is uncommon, and the mainstay of treatment is symptomatic in most patients.
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Morren JA, Levin KH, Shields RW. Diagnostic Accuracy of Single Fiber Electromyography for Myasthenia Gravis in Patients Followed Longitudinally. J Clin Neurophysiol 2017; 33:469-474. [PMID: 27749461 DOI: 10.1097/wnp.0000000000000285] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The literature lacks data on accuracy of single fiber electromyography (SFEMG) for myasthenia gravis (MG) patients followed longitudinally. METHODS We included patients with a clinical suspicion of MG who received SFEMG and follow-up at our institution between 2003 and 2013. Data collected included demographics, symptom details, clinical deficits, other diagnostic testing results, MG medication regimen, duration on treatment, response to therapy, and ultimate diagnosis after follow-up. When available, information was also extracted from the MG-specific Activities of Daily Living, MG Quality of Life, and European Quality of Life assessments before and after SFEMG. RESULTS Three hundred forty eight SFEMG patients met inclusion criteria. Myasthenia gravis was ultimately diagnosed in 31% (19% ocular, 12% generalized). A sensitivity of 78% was seen for MG regardless of subtype, 73% for ocular MG, and 85% for generalized MG. A specificity of 91% was obtained for MG of either ocular or generalized subtype. CONCLUSIONS The diagnostic accuracy of SFEMG using this methodology minimizing incorporation bias is more reliable than that usually described in previous studies. There is utility in increasing diagnostic yield when SFEMG results are combined with clinical data and those from other diagnostic tests, particularly serology.
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Affiliation(s)
- John A Morren
- *Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.; and †Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
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Kim DI, Lee BJ, Kim SJ. Intravenous Neostigmine Test for Diagnosis of Ocular Myasthenia Gravis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2017. [DOI: 10.3341/jkos.2017.58.1.74] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Dong Ik Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Joo Lee
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Joon Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
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Baruca M, Leonardis L, Podnar S, Hojs-Fabjan T, Grad A, Jerin A, Blagus R, Šega-Jazbec S. Single fiber EMG as a prognostic tool in myasthenia gravis. Muscle Nerve 2016; 54:1034-1040. [DOI: 10.1002/mus.25174] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 04/27/2016] [Accepted: 05/02/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Mateja Baruca
- University Medical Centre Ljubljana, Department of Neurology; Zaloška cesta 2,1000 Ljubljana Slovenia
| | - Lea Leonardis
- University Medical Centre Ljubljana, Institute of Clinical Neurophysiology; Ljubljana Slovenia
| | - Simon Podnar
- University Medical Centre Ljubljana, Institute of Clinical Neurophysiology; Ljubljana Slovenia
| | | | - Anton Grad
- General Hospital of Isola; Isola Slovenia
| | - Aleš Jerin
- University Medical Centre Ljubljana, Clinical institute of Clinical Chemistry and biochemistry; Ljubljana Slovenia
| | - Rok Blagus
- Institute for Biostatistics and Medical Informatics; University of Ljubljana, Faculty of Medicine; Ljubljana Slovenia
| | - Saša Šega-Jazbec
- University Medical Centre Ljubljana, Department of Neurology; Zaloška cesta 2,1000 Ljubljana Slovenia
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Karni A, Asmail A, Drory VE, Kolb H, Kesler A. Characterization of patients with ocular myasthenia gravis - A case series. eNeurologicalSci 2016; 4:30-33. [PMID: 29430546 PMCID: PMC5803088 DOI: 10.1016/j.ensci.2016.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 04/23/2016] [Indexed: 11/12/2022] Open
Abstract
Ocular myasthenia gravis (OMG) is sometimes difficult to diagnose and is probably both under-diagnosed and misdiagnosed. We studied the epidemiological parameters, relevant serology, electromyographic (EMG) findings, and the relationship between OMG and thymoma, thymus hyperplasia and other autoimmune disorders compared to generalized MG (GMG) in a case control study of 133 patients with MG (32 patients with OMG and 101 patients with GMG). The proportion of OMG among all MG patients was relatively high (24.1%). It affected more males than females and its onset was at an older age. Although anti-AChR Ab was detected in fewer OMG patients compared to GMG patients, the rate of positive serology in OMG patients was higher than previously reported. Male OMG patients had a higher positive serology rate than female OMG patients. OMG patients tended to have less supportive EMG evidence of neuromuscular disorder. Female OMG patients had higher rates of thymus hyperplasia and higher rates of other autoimmune disorders than males. Diagnosing MG in patients with solitary ocular manifestation may be difficult due to lower rates of paraclinic supportive tests. Awareness of the characteristics of OMG is important in order to avoid delayed or misdiagnosis of MG and to prevent avoidable iatrogenic complications.
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Affiliation(s)
- Arnon Karni
- Neuroimmunology Clinic, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ali Asmail
- Neuroimmunology Clinic, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vivian E. Drory
- Neuromuscular Service of the Department of Neurology, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Kolb
- Neuroimmunology Clinic, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Kesler
- Neuro-ophthalmology Unit of the Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Mangaraj S, Choudhury AK, Mohanty BK, Baliarsinha AK. Neurological manifestations of Graves' disease: A case report and review of the literature. J Neurosci Rural Pract 2016; 7:153-6. [PMID: 26933368 PMCID: PMC4750319 DOI: 10.4103/0976-3147.165393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Graves’ disease (GD) is characterized by a hyperfunctioning thyroid gland due to stimulation of the thyroid-stimulating hormone receptor by autoantibodies directed against it. Apart from thyrotoxicosis, other clinical manifestations include ophthalmopathy, dermopathy, and rarely acropachy. GD is an organ-specific autoimmune disorder, and hence is associated with various other autoimmune disorders. Myasthenia gravis (MG) is one such disease, which is seen with patients of GD and vice versa. Though the association of GD and myasthenia is known, subtle manifestations of latter can be frequently missed in routine clinical practice. The coexistence of GD and ocular MG poses a significant diagnostic dilemma to treating physicians. The ocular manifestations of myasthenia can be easily missed in case of GD and falsely attributed to thyroid associated ophthalmopathy due to closely mimicking presentations of both. Hence, a high degree of the clinical vigil is necessary in such cases to appreciate their presence. We present a similar case which exemplifies the above said that the clinical challenge in diagnosing coexistent GD and ocular myasthenia.
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Affiliation(s)
| | | | - Binoy Kumar Mohanty
- Department of Endocrinology, S. C. B Medical College, Cuttack, Odisha, India
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Zambelis T, Pappas V, Kokotis P, Zouvelou V, Karandreas N. Patients with ocular symptoms referred for electrodiagnosis: how many of them suffer from myasthenia gravis? Acta Neurol Belg 2015; 115:671-4. [PMID: 25822064 DOI: 10.1007/s13760-015-0460-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Accepted: 03/16/2015] [Indexed: 11/28/2022]
Abstract
The aim of this study was the diagnosis of patients with isolated ocular manifestations (ptosis and/or diplopia) referred for electrophysiological evaluation to the electrodiagnostic laboratory of a University Neurological Department. Examination was performed either in inpatient status or in outpatient basis. We analyzed the clinical, electrophysiological and other laboratory data in 79 subjects. Myasthenia gravis (MG) was diagnosed in 38 %, 45.6 % in other diseases (Graves disease, blepharospasm, IIId cranial verve palsy, multiple sclerosis, stroke, etc.), while in 16.5 %, the cause remained unidentified. Symptoms fluctuation was significantly more frequent in the myasthenic patients, compared to patients with other diseases. The presence of both diplopia and ptosis are more likely due to MG rather than other pathology.
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Affiliation(s)
- Th Zambelis
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece.
| | - V Pappas
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
| | - P Kokotis
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
| | - V Zouvelou
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
| | - N Karandreas
- Department of Neurology, EMG Laboratory, University of Athens, Aeginition Hospital, 74, Vass. Sofias Ave., 115-28, Athens, Greece
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Long-term outcome of 424 childhood-onset myasthenia gravis patients. J Neurol 2015; 262:823-30. [DOI: 10.1007/s00415-015-7638-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/01/2015] [Accepted: 01/03/2015] [Indexed: 10/24/2022]
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Murai H. Japanese clinical guidelines for myasthenia gravis: Putting into practice. ACTA ACUST UNITED AC 2015. [DOI: 10.1111/cen3.12180] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Hiroyuki Murai
- Department of Neurology; Neurological Institute; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
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Tamburrini A, Tacconi F, Barlattani A, C. Mineo T. An update on myasthenia gravis, challenging disease for the dental profession. J Oral Sci 2015; 57:161-8. [DOI: 10.2334/josnusd.57.161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Alessandro Tamburrini
- Thoracic Surgery Division, Multidisciplinary Myasthenia Gravis Unit, Tor Vergata University
| | - Federico Tacconi
- Thoracic Surgery Division, Multidisciplinary Myasthenia Gravis Unit, Tor Vergata University
| | | | - Tommaso C. Mineo
- Thoracic Surgery Division, Multidisciplinary Myasthenia Gravis Unit, Tor Vergata University
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Abstract
Myasthenia gravis in children can be generalized or ocular, and associated with antibodies to acetylcholine receptors or muscle-specific kinase, but it can be negative for those antibodies (seronegative). It needs to be distinguished from congenital myasthenic syndromes and other neuromuscular diseases. In the perinatal period, transient neonatal myasthenia and arthrogryposis multiplex congenita, due to maternal antibodies, need to be considered. Juvenile myasthenia is similar in presentation and treatment to that in adults. Here we present guidelines for recognition, diagnosis, and treatment.
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Kohler S, Keil TOP, Swierzy M, Hoffmann S, Schaffert H, Ismail M, Rückert JC, Alexander T, Hiepe F, Gross C, Thiel A, Meisel A. Disturbed B cell subpopulations and increased plasma cells in myasthenia gravis patients. J Neuroimmunol 2013; 264:114-9. [PMID: 24099983 DOI: 10.1016/j.jneuroim.2013.09.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 08/27/2013] [Accepted: 09/11/2013] [Indexed: 12/26/2022]
Abstract
Whether there is a general perturbation of B and plasma cell subsets in myasthenia gravis (MG) has not been investigated so far. Here we performed a detailed flow cytometric analysis of blood and if available thymic tissue in order to detect MG-specific and therapy-induced changes. We observed significant differences in the distribution of B cell subsets in MG patients, yet these were mainly attributable to medical treatment. Furthermore MG is associated with significantly increased frequencies of plasma cells that were especially activated in purely ocular disease manifestation. In contrast to thymoma, B cell subset distribution in hyperplastic thymus could be distinguished from peripheral blood, however both tissues were not significantly enriched with plasma cells. Thus B cell differentiation in general is not defective in MG, but modified by therapy and enhanced frequencies of plasma cells can be detected in MG patients.
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Affiliation(s)
- Siegfried Kohler
- Department of Experimental Neurology, Charité-University Medicine Berlin, Germany; Department of Neurology, Charité-University Medicine Berlin, Germany.
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Abstract
Juvenile myasthenia gravis is an uncommon autoimmune disorder. Its management is not standardized. Juvenile myasthenia gravis is pathophysiologically similar to myasthenia gravis in adults. However, a number of significant particularities related to race, age at onset, severity, and antibody status complicate the management. We summarize the unique clinical features of juvenile myasthenia gravis and review the therapeutic options.
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Affiliation(s)
- Cristian M Ionita
- Connecticut Children's Medical Center, Department of Pediatrics, and Division of Pediatric Neurology, Department of Neurology, University of Connecticut School of Medicine, Hartford, CT 06106, USA.
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Ocular myasthenia gravis in an academic neuro-ophthalmology clinic: clinical features and therapeutic response. J Clin Neuromuscul Dis 2012; 13:46-52. [PMID: 22361625 DOI: 10.1097/cnd.0b013e31821c5634] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The frequency of ocular myasthenia gravis (OMG) in patients referred to an academic neuro-ophthalmology clinic for suspected myasthenia gravis is not known. Our objective was to determine the frequency of ocular OMG in patients referred to an academic neuro-ophthalmologist and determine alternate diagnoses and response to therapy. METHODS We performed a retrospective chart review of patients presenting to the University of Kansas Neuro-Ophthalmology Clinic with suspected OMG over 9 years. We defined OMG as isolated ptosis/diplopia at initial presentation supported by at least one of the following abnormal tests: edrophonium test, ice test, Cogan lid twitch, fatigability on sustained upgaze, acetylcholine receptor binding antibody, greater than 10% decrement on repetitive stimulation, or abnormal single-fiber jitter. We also determined the cause of ptosis/diplopia if it was not the result of OMG. Patients who progressed from OMG to generalized disease were termed transformed myasthenia gravis (TMG). RESULTS One hundred thirty-eight patients were referred with mean age at presentation 58 ± 19 years. Myasthenia gravis was diagnosed in 101 patients; 95 had OMG; six had generalized MG. Diagnosis in the other 37 was cranial nerve palsies (nine), levator dehiscence (five), multiple sclerosis (two), blepharospasm (two), decompensated phorias (three), accommodation spasm (four), exophoria (three), skew deviation (two), Graves disease (one), hypertropia (one), myopathy (one), neurosarcoidosis (one), progressive supranuclear palsy (one), Miller Fisher variant of Guillain-Barre syndrome (one), and obstructive sleep apnea (one). Mean follow-up was 3.0 ± 2.8 years. Test sensitivity/specificity in OMG was fatigability on sustained upgaze 0.80/0.63; ice pack 0.80/0.25; Cogan lid twitch 0.59/1.00; edrophonium 0.88/0.50; acetylcholine receptor binding antibody 0.38/1.00; repetitive nerve stimulation 0.24/1.00; and single-fiber electromyography 0.90/1.00. Pyridostigmine was used without prednisone in 59 of 97 patients with OMG and 12 of 59 developed TMG. Prednisone was used in 38 patients; 21 of 38 (55%) met Myasthenia Gravis Foundation of America improvement status and none had TMG. CONCLUSION The diagnosis of myasthenia gravis was confirmed in the majority of patients referred to our academic neuro-ophthalmology clinic, but 27% did not have myasthenia gravis. It is possible that prednisone treatment of OMG may prevent progression to TMG, but further study is required.
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Abstract
OPINION STATEMENT Myasthenia gravis (MG) is an autoimmune disorder that is characterized by variable weakness and fatigability. Often, MG presents with only ocular symptoms such as ptosis and diplopia. Treatment of ocular MG is aimed at relieving the symptoms of ptosis and diplopia, as well as preventing the development of generalized MG symptoms. Immune suppression with steroids is often the main therapy. Steroid doses must be increased slowly because of a risk of precipitating myasthenic crisis. After achieving the highest target dose, steroids are then slowly tapered down to the lowest effective dose. Often, acetylcholinesterase inhibitors such as pyridostigmine and neostigmine are also employed to help control symptoms. When steroids are contraindicated, acetylcholinesterase inhibitors can be tried as the primary therapy. Steroid-sparing agents such as azathioprine and mycophenolate may also have a role in treating ocular MG. Other treatments for MG include plasmapheresis, intravenous immunoglobulin, and other immunosuppressive agents, but these are rarely required for ocular MG. Patients should also be evaluated for thymoma. Thymoma should be resected surgically. Ocular MG without thymoma is not usually treated with thymectomy. Topical agents may be useful as additional therapy for mild or moderate ptosis. Nonpharmacologic treatments include occlusive devices, prisms, eyelid supports, contact lenses, and (in long-standing, stable cases) strabismus surgery or eyelid elevation surgery.
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Díaz-Manera J, Rojas García R, Illa I. Treatment strategies for myasthenia gravis: an update. Expert Opin Pharmacother 2012; 13:1873-83. [DOI: 10.1517/14656566.2012.705831] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Shi QG, Wang ZH, Ma XW, Zhang DQ, Yang CS, Shi FD, Yang L. Clinical significance of detection of antibodies to fetal and adult acetylcholine receptors in myasthenia gravis. Neurosci Bull 2012; 28:469-74. [PMID: 22961471 DOI: 10.1007/s12264-012-1256-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 05/23/2012] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the frequency, distribution and clinical significance of the antibodies to the fetal and/or adult acetylcholine receptor (AChR) in patients with myasthenia gravis (MG). METHODS AChR antibodies were detected by cell-based assay in the serum of ocular MG (OMG) (n = 90) and generalized MG (GMG) patients (n = 110). The fetal-type (2α: β: γ: δ) and adult-type (2α: β: ε: δ) AChR were used as antigens, and their relevance to disease presentation was assessed. RESULTS The overall frequencies of anti-adult and anti-fetal AChR antibodies were similar in all 200 patients examined, with 14 having serum specific to the AChR-Γ subunit, and 22 to the AChR-ε subunit. The overall sensitivity when using the fetal and adult AChR antibodies was higher than that when using the fetal AChR antibody only (P = 0.015). Compared with OMG patients, the mean age at disease onset and the positive ratio of antibodies to both isoforms of the AChR were significantly higher in patients who subsequently progressed to GMG. Older patients and patients with both anti-fetal and anti-adult AChR antibodies had a greater risk for developing generalized disease [odds ratio (OR), 1.03; 95% confidence interval (CI), 1.01-1.06 and OR, 5.09; 95% CI, 2.23-11.62]. CONCLUSION Using both fetal- and adult-type AChRs as the antigens may be more sensitive than using either subtype. Patients with serum specific to both isoforms are at a greater risk of progressing to GMG. Patients with disease onset at an advanced age appear to have a higher frequency of GMG conversion.
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Affiliation(s)
- Qi-Guang Shi
- Department of Neurology and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, 300052, China
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HLA-DQA1*03:02/DQB1*03:03:02 is strongly associated with susceptibility to childhood-onset ocular myasthenia gravis in Southern Han Chinese. J Neuroimmunol 2012; 247:81-5. [DOI: 10.1016/j.jneuroim.2012.03.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Revised: 02/29/2012] [Accepted: 03/18/2012] [Indexed: 11/19/2022]
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Abstract
Acquired myasthenia gravis (MG) is a chronic autoimmune disorder of the neuromuscular junction, characterized clinically by muscle weakness and abnormal fatigability on exertion. Current guidelines and recommendations for MG treatment are based largely on clinical experience, retrospective analyses and expert consensus. Available therapies include oral acetylcholinesterase (AChE) inhibitors for symptomatic treatment, and short- and long-term disease-modifying treatments. This review focuses on treatment of MG, mainly on the use of the AChE inhibitor pyridostigmine. Despite a lack of data from well controlled clinical trials to support their use, AChE inhibitors, of which pyridostigmine is the most commonly used, are recommended as first-line therapy for MG. Pyridostigmine has been used as a treatment for MG for over 50 years and is generally considered safe. It is suitable as a long-term treatment in patients with generalized non-progressive milder disease, and as an adjunctive therapy in patients with severe disease who are also receiving immunotherapy. Novel AChE inhibitors with oral antisense oligonucleotides have been developed and preliminary results appear to be promising. In general, however, AChE inhibitors provide only partial benefit and most patients eventually switch to long-term immunosuppressive therapies, most frequently corticosteroids and/or azathioprine. Although AChE inhibitors are known to be well tolerated and effective in relieving the symptoms of MG, further efforts are required to improve treatment options for the management of this disorder.
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Romi F, Helgeland G, Gilhus NE. Serum Levels of Matrix Metalloproteinases: Implications in Clinical Neurology. Eur Neurol 2012; 67:121-8. [DOI: 10.1159/000334862] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 11/04/2011] [Indexed: 12/11/2022]
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Anti-voltage-gated potassium channel Kv1.4 antibodies in myasthenia gravis. J Neurol 2011; 259:1312-6. [PMID: 22167224 DOI: 10.1007/s00415-011-6344-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 11/09/2011] [Accepted: 11/29/2011] [Indexed: 01/17/2023]
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by skeletal muscle weakness mainly caused by acetylcholine receptor antibodies. MG can be divided into generalized and ocular, and into early-onset (<50 years of age) and late-onset (≥50 years of age). Anti-Kv1.4 antibodies targeting α-subunits (Kv1.4) of the voltage-gated potassium K(+) channel occurs frequently among patients with severe MG, accounting for 18% of a Japanese MG population. The aim of this study was to characterize the clinical features and serological associations of anti-Kv1.4 antibodies in a Caucasian MG population with mild and localized MG. Serum samples from 129 Caucasian MG patients with mainly ocular symptoms were tested for the presence of anti-Kv1.4 antibodies and compared to clinical and serological parameters. There were 22 (17%) anti-Kv1.4 antibody-positive patients, most of them women with late-onset MG, and all of them with mild MG. This contrasts to the Japanese anti-Kv1.4 antibody-positive patients who suffered from severe MG with bulbar symptoms, myasthenic crisis, thymoma, myocarditis and prolonged QT time on electrocardiography, despite equal anti-Kv1.4 antibody occurrence in both populations. No other clinical or serological parameters influenced anti-Kv1.4 antibody occurrence.
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Finnis MF, Jayawant S. Juvenile myasthenia gravis: a paediatric perspective. Autoimmune Dis 2011; 2011:404101. [PMID: 22110902 PMCID: PMC3206364 DOI: 10.4061/2011/404101] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 08/10/2011] [Indexed: 11/25/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease in which antibodies are directed against the postsynaptic membrane of the neuromuscular junction, resulting in muscle weakness and fatigability. Juvenile myasthenia gravis (JMG) is a rare condition of childhood and has many clinical features that are distinct from adult MG. Prepubertal children in particular have a higher prevalence of isolated ocular symptoms, lower frequency of acetylcholine receptor antibodies, and a higher probability of achieving remission. Diagnosis in young children can be complicated by the need to differentiate from congenital myasthenic syndromes, which do not have an autoimmune basis. Treatment commonly includes anticholinesterases, corticosteroids with or without steroid-sparing agents, and newer immune modulating agents. Plasma exchange and intravenous immunoglobulin (IVIG) are effective in preparation for surgery and in treatment of myasthenic crisis. Thymectomy increases remission rates. Diagnosis and management of children with JMG should take account of their developmental needs, natural history of the condition, and side-effect profiles of treatment options.
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Affiliation(s)
- Maria F Finnis
- Department of Paediatric Neurology, Children's Hospital, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Zambelis T, Kokotis P, Karandreas N. Repetitive nerve stimulation of facial and hypothenar muscles: relative sensitivity in different myasthenia gravis subgroups. Eur Neurol 2011; 65:203-7. [PMID: 21412008 DOI: 10.1159/000324915] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 02/06/2011] [Indexed: 11/19/2022]
Abstract
AIM To assess the utility of repetitive nerve stimulation (RNS) in facial and hypothenar muscles in the clinical groups of myasthenia gravis (MG). PATIENTS AND METHODS We performed RNS study in the orbicularis oculi (O.O.), nasalis and abductor digiti quinti (ADQ) in 115 consecutive myasthenic patients and classified them according to the classifications of the Myasthenia Gravis Foundation of America. Patients were classified into three groups: group 1, group 2 (IIa, IIIa and IVa) and group 3 (IIb, IIIb and IVb). RESULTS RNS was abnormal in 95 patients (82.6%): 78.3% in the O.O., 66.1% in the nasalis and 19.1% in the ADQ. Both facial muscles were statistically more sensitive than the ADQ in all groups of patients. RNS in the O.O. was more frequently abnormal than in the nasalis only in group 1. Sensitivity to acetylcholine antibodies in myasthenic patients was 84%. Acetylcholine receptor (AChR) and muscle-specific tyrosine kinase antibodies were present in 96.7% of the patients with abnormal RNS in both facial muscles. Single-fiber electromyogram (SFEMG) was abnormal in 91.3% of the tested patients. One of the three tests used for the diagnosis of MG (AChR antibodies, SFEMG, RNS) was abnormal in 99.1% of the patients. DISCUSSION O.O. is the most sensitive muscle in all groups of MG followed by nasalis, while the ADQ is the muscle with the lowest sensitivity. Facial muscles, especially the O.O., should be the first to be tested in MG. The negativity of all tests (RNS, AChR antibodies, SFEMG) should question the diagnosis of MG, even in the presence of symptoms consistent with MG.
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Affiliation(s)
- T Zambelis
- Department of Neurology, University of Athens, Aeghinition Hospital, Athens, Greece.
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Romi F, Helgeland G, Gilhus NE. Heat-Shock Proteins in Clinical Neurology. Eur Neurol 2011; 66:65-9. [DOI: 10.1159/000329373] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 05/16/2011] [Indexed: 11/19/2022]
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Mantegazza R, Bonanno S, Camera G, Antozzi C. Current and emerging therapies for the treatment of myasthenia gravis. Neuropsychiatr Dis Treat 2011; 7:151-60. [PMID: 21552317 PMCID: PMC3083988 DOI: 10.2147/ndt.s8915] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Indexed: 11/23/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmmune disease in which autoantibodies to different antigens of the neuromuscular junction cause the typical weakness and fatigability. Treatment includes anticholinesterase drugs, immunosuppression, immunomodulation, and thymectomy. The autoimmune response is maintained under control by corticosteroids frequently associated with immunosuppressive drugs, with improvement in the majority of patients. In case of acute exacerbations with bulbar symptoms or repeated relapses, modulation of autoantibody activity by plasmapheresis or intravenous immunoglobulins provides rapid improvement. Recently, techniques removing only circulating immunoglobulins have been developed for the chronic management of treatment-resistant patients. The rationale for thymectomy relies on the central role of the thymus. Despite the lack of controlled studies, thymectomy is recommended as an option to improve the clinical outcome or promote complete remission. New videothoracoscopic techniques have been developed to offer the maximal surgical approach with the minimal invasiveness and hence patient tolerability. The use of biological drugs such as anti-CD20 antibodies is still limited but promising. Studies performed in the animal model of MG demonstrated that several more selective or antigen-specific approaches, ranging from mucosal tolerization to inhibition of complement activity or cellular therapy, might be feasible. Investigation of the transfer of these therapeutic approaches to the human disease will be the challenge for the future.
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Affiliation(s)
- Renato Mantegazza
- Department of Neuromuscular Diseases and Neuroimmunology, Fondazione Istituto Neurologico Carlo Besta, Milan, Italy
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Ophthalmologic manifestations commonly misdiagnosed as demyelinating events in multiple sclerosis patients. Curr Opin Ophthalmol 2010; 21:436-41. [PMID: 20736835 DOI: 10.1097/icu.0b013e32833eade6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Multiple sclerosis may affect both afferent and efferent visual pathways, and sometimes physicians err on ordinary ophthalmologic diagnosis due to overlapping symptoms between demyelinating and nondemyelinating visual diseases. The present article highlights nondemyelinating ocular occurrences due to physiologic or other pathologic processes that may appear in some patients. RECENT FINDINGS Optic neuritis is representative of the most common and best-studied demyelinating visual occurrence in multiple sclerosis. However, other nondemyelinating visual disturbances also seen in the general population may be erroneously interpreted as being part of the underlying disease. This comparison has not been documented and may be helpful to overcome such difficulties. SUMMARY Based on clinical history and some strategies of ophthalmologic examination, physicians can achieve the correct diagnosis. Some clinical situations, however, may be challenging and a multidisciplinary approach in the care of multiple sclerosis is warranted.
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Helgeland G, Petzold A, Hoff JM, Gilhus NE, Plant GT, Romi FR. Anti-Heat Shock Protein 70 antibody levels are increased in myasthenia gravis and Guillain-Barré syndrome. J Neuroimmunol 2010; 225:180-3. [DOI: 10.1016/j.jneuroim.2010.04.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 04/19/2010] [Accepted: 04/30/2010] [Indexed: 10/19/2022]
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Appenzeller S, Veilleux M, Clarke A. Third cranial nerve palsy or pseudo 3rd nerve palsy of myasthenia gravis? A challenging diagnosis in systemic lupus erythematosus. Lupus 2009; 18:836-40. [PMID: 19578109 DOI: 10.1177/0961203308101546] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diplopia is frequently encountered in neurological practice and may occur as part of the clinical spectrum of 3rd cranial nerve palsy. Correct localization of the underlying problem is the first step in making an accurate diagnosis. Pathologies affecting the supranuclear structures, cranial nerves and nuclei, extraocular muscles and the neuromuscular junction may cause or simulate 3rd nerve palsy. We report a case of a patient with longstanding quiescent SLE who presented with sudden onset of diplopia and discuss possible aetiologies including ischemia, demyelination, neuromuscular conditions and medication-induced.
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Affiliation(s)
- S Appenzeller
- Division of Clinical Immunology/Allergy, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Díaz-Manera J, Rojas-García R, Illa I. Treatment strategies for myasthenia gravis. Expert Opin Pharmacother 2009; 10:1329-42. [DOI: 10.1517/14656560902950619] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
Acquired myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction in which patients experience fluctuating skeletal muscle weakness that often affects selected muscle groups preferentially. The target of the autoimmune attack in most cases is the skeletal muscle acetylcholine receptor (AChR), but in others, non-AChR components of the neuromuscular junction, such as the muscle-specific receptor tyrosine kinase, are targeted. The pathophysiological result is muscle endplate dysfunction and consequent fatigable muscle weakness. Clinical presentations vary substantially, both for anti-AChR positive and negative MG, and accurate diagnosis and selection of effective treatment depends on recognition of less typical as well as classic disease phenotypes. Accumulating evidence suggests that clinical MG subgroups might respond differently to treatment. In this Review, we provide current information about the epidemiology, immunopathogenesis, clinical presentations, diagnosis, and treatment of MG, including emerging therapeutic strategies.
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Affiliation(s)
- Matthew N Meriggioli
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Current world literature. Curr Opin Neurol 2008; 21:615-24. [PMID: 18769258 DOI: 10.1097/wco.0b013e32830fb782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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