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Croitoru CG, Pavel-Tanasa M, Cuciureanu DI, Hodorog DN, Cianga P. Autoimmune and Non-Autoimmune Comorbidities in Myasthenic Patients of East-European Descent: A Case-Control Study. J Clin Med 2024; 13:2273. [PMID: 38673546 PMCID: PMC11051044 DOI: 10.3390/jcm13082273] [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: 02/17/2024] [Revised: 04/08/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Background: As the life expectancy of patients with myasthenia gravis (MG) is improving, so the number of comorbidities continues to rise, with a potentially significant impact on the overall morbidity and mortality. The main aim of the study was to assess comorbidities of MG in a group of patients of East-European descent. Methods: We retrospectively compared 185 adult myasthenic patients with 895 sex- and age-matched controls, admitted from January 2013 to December 2021. Results: Of these patients, 60% had late-onset MG (LOMG), with a clear predominance of women in both the LOMG and early-onset (EOMG) types; and 23.8% of the patients had a radiological description consistent with thymoma. All myasthenic patients had at least one comorbidity; 20 (10.8%) of the patients associated at least one autoimmune comorbidity. Obesity (p < 0.01), type 2 diabetes (p < 0.0001), cerebrovascular diseases (p < 0.0001), essential hypertension (p < 0.01), and cardiac arrythmias (p < 0.0001) were more frequent in patients than in the control group. The granulocyte-to-lymphocyte ratio was higher in the myasthenic patients compared to the controls (p < 0.01 for LOMG). Discussion: We, thus, suggest a common chronic low-grade inflammatory background as a possible connection between MG subtypes and some of these apparently unconnected comorbidities. Conclusions: The East-European origin of the patients offered a different social and cultural angle of a disease studied mainly on populations of West-European and Asian descent.
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Affiliation(s)
- Cristina Georgiana Croitoru
- I Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, 700309 Iași, Romania
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
| | - Mariana Pavel-Tanasa
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
| | - Dan Iulian Cuciureanu
- I Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, 700309 Iași, Romania
- Department Medical III, Discipline of Neurology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Diana Nicoleta Hodorog
- I Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, 700309 Iași, Romania
- Department Medical III, Discipline of Neurology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Petru Cianga
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
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Li K, Ouyang Y, Yang H. Myasthenia gravis and five autoimmune diseases: a bidirectional Mendelian randomization study. Neurol Sci 2024; 45:1699-1706. [PMID: 37910321 DOI: 10.1007/s10072-023-07163-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/18/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The association between myasthenia gravis (MG) and other autoimmune diseases is well established. In this study, we aimed to investigate the causal effects between MG and five other autoimmune diseases, including autoimmune thyroid disease (AITD), multiple sclerosis (MS), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and type 1 diabetes (T1DM). METHODS We conducted a bidirectional Mendelian randomization (MR) study by using seven published genome-wide association studies (GWAS), including MG (1873 patients versus 36,370 controls), AITD (autoimmune hypothyroidism) (22,997 patients versus 175,475 controls), AITD (autoimmune hyperthyroidism) (962 patients versus 172,976 controls), MS (47,429 patients versus 68,374 controls), RA (14,361 patients versus 43,923 controls), SLE (4222 patients versus 8431 controls), and T1DM (9266 patients versus 15,574 controls). We used the inverse-variance-weighted (IVW) method, weighted-median (WM) estimator, MR-Egger regression, and MR PRESSO in our analyses. We also carried out detailed sensitivity analyses for each direction using the aforementioned methods. RESULTS When MG was treated as the exposure, MR evidence suggested a causal relationship between MG and T1DM, SLE, AITD (both hypothyroidism and hyperthyroidism), and MS (excluding RA). Using the IVW method, we found that MG was associated with increased risk of T1DM (OR = 1.94; 95% CI, 1.16-3.26; p = 0.012), SLE (OR = 1.47; 95% CI, 1.02-2.13; p = 0.04), AITD (hypothyroidism) (OR = 1.31; 95% CI, 1.02-1.68; p = 0.039), AITD (hyperthyroidism) (OR = 1.55; 95% CI, 1.15-2.09; p = 0.004), and MS (OR = 1.46; 95% CI, 1.01-2.09; p = 0.041). When MG was treated as the outcome, MR evidence suggested that RA, T1DM, and SLE were causal factors in MG. Using the IVW method, we found that the risk of MG increased with exposure to RA (OR = 1.21; 95% CI, 1.08-1.37; p = 0.002), T1DM (OR = 1.09; 95% CI, 1.02-1.16; p = 0.006), and SLE (OR = 1.12; 95% CI, 1.02-1.23; p = 0.018). CONCLUSIONS This study demonstrated a causal relationship between MG and several other autoimmune diseases. Our results supported a bidirectional causal association between MG and SLE/T1DM. Our findings also provided reliable evidence that MG is associated with increased risk of AITD. Meanwhile, we also showed that RA is a possible causal driver of MG risk.
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Affiliation(s)
- Kailin Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410013, China
| | - Yuzhen Ouyang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410013, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410013, China.
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Manuja N, Kumar S, Acharya S, Daiya V, Sood A. Simultaneous Myasthenic Crisis With Thyrotoxic Crisis in an Adult Male: An Autoimmune Overlap. Cureus 2023; 15:e44366. [PMID: 37779793 PMCID: PMC10540243 DOI: 10.7759/cureus.44366] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
When it comes to thyroid disorders, Graves' disease (GD) is the most prevalent autoimmune thyroid disorder in which antibodies are formed against thyroid receptors. Myasthenia gravis (MG) is a rare autoimmune neuromuscular junction disorder. Autoimmune antibodies are formed against postsynaptic neuromuscular junctions in MG, interrupting neuromuscular transmission and causing variable muscle weakness and tiredness. It affects older men and young women. The two disorders may coexist in a patient, or either of them may develop first. The thyroid condition GD is most frequently linked to MG. This case report describes an older man who presented with an acute exacerbation of MG along with a thyrotoxic crisis.
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Affiliation(s)
- Nishtha Manuja
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Varun Daiya
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anshul Sood
- Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Hashimoto's Encephalopathy: Case Series and Literature Review. Curr Neurol Neurosci Rep 2023; 23:167-175. [PMID: 36853554 PMCID: PMC9972331 DOI: 10.1007/s11910-023-01255-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE OF REVIEW To describe the clinical manifestations of Hashimoto's encephalopathy (HE) and discuss its pathogenesis in light of recent research. RECENT FINDINGS The pathogenesis of HE is uncertain. Available evidences point towards an autoimmune etiology due to vasculitis or other inflammatory process. Detection of thyroid antibodies - antithyroid peroxidase and anti-thyroglobulin are essential for diagnosis. Autoimmune encephalitis including Anti-IgLON5 disease needs to be excluded in suspected cases with appropriate tests for neuronal surface antibodies. Detection of thyroid autoantibodies is nonspecific, as these can be detected in some normal individuals and in other autoimmune diseases. In recent years, attention has turned to an aggressive form of Hashimoto's thyroiditis accompanied by elevated serum IgG4 levels in younger males with very high levels of thyroid antibodies. The role of the thyroid autoantibodies in the central nervous system (CNS) tissue damage remains unclear and these can act only as markers for diagnosis. Conversely, they have a role to play in determining the thyroid pathology - more glandular fibrosis associated with thyro-peroxidase antibody than with the thyroglobulin antibody. HE is a syndrome characterized by altered mental status, confusion, hallucinations, delusions, and sometimes seizures, in association with high serum anti-thyroid antibody concentration that is usually responsive to glucocorticoid therapy. Diagnosis requires the exclusion of other causes of encephalopathies and encephalitis including autoimmune encephalitis associated with neuronal surface antibodies and paraneoplastic ones. Diagnosis also is dependent on the demonstration of thyroid autoantibodies in serum. Since there is no direct pathophysiologic link between antithyroid antibodies, Hashimoto thyroiditis and the cerebral syndrome, the nomenclature HE could be misleading. The response to steroids led to a renaming of the syndrome to steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT), though some cases do not respond to steroids. In recent years, attention has turned to an aggressive form of Hashimoto's thyroiditis accompanied by elevated serum IgG4 levels (IgG4-related disease). This is characterized by a higher incidence in men (5:1) than in women, onset at a younger age, more intense thyroid inflammation and higher antithyroid antibody titters. Such patients have excessive production of IgG4 + plasmacytes, which infiltrate various organs leading to their fibrosis and sclerosis, sometimes resulting in inflammatory tumors. HE is treated with corticosteroids along with treatment of the dysthyroid condition, if any. There are yet no guidelines regarding steroid dose and/or duration.
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5
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Tian W, He J, Yu H, Sun Y, Wu Q, Jiao P, Ma C, Huang C, Li D, Tong H. Clinical characteristics of myasthenia gravis (MG) patients developing other autoimmune diseases after thymectomy from one single center cohort. Thorac Cancer 2022; 14:135-142. [PMID: 36419347 PMCID: PMC9834700 DOI: 10.1111/1759-7714.14723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Myasthenia gravis (MG) patients are reported to have a high risk of other autoimmune diseases (ADs), and thymectomy may increase the risk further. A cohort of MG patients in which thymectomy was performed were investigated to analyze the prevalence, types and features of the new onset ADs. METHODS Consecutive patients with MG who underwent thymectomy at Beijing Hospital between January 2012 and August 2021 were retrospectively enrolled. Patients with a postoperative follow-up period shorter than a year or incomplete clinical records were excluded. Clinical and follow-up data were collected. Statistical analyses were performed using SPSS version 22.0. RESULTS A total of 445 patients were included in this study. The median follow-up period was 72 months (range, 12-135 months). A total of 63 (14.2%) MG patients had concurrent ADs. The incidence rate was higher than the background prevalence of population (5%), and also higher than that of a former Chinese MG cohort (11.6%). A total of 47 patients (10.6%) were diagnosed with ADs before thymectomy, and 19 (4.3%) developed a new AD after thymectomy. The most common types of new onset ADs after thymectomy were Hashimoto's thyroiditis and rheumatoid arthritis (RA), which were different from those before thymectomy (hyperthyroidism and Hashimoto's thyroiditis). The incidence rate of new onset RA (1.35%) was higher than the frequency of RA before thymectomy (0.45%), and also higher than the incidence rate in a Chinese MG cohort (0.5%). There was a higher proportion of female patients (p = 0.026) with postoperative ADs. A younger age at operation may increase the risk of nonthymoma MG patients (p = 0.040) developing ADs. The postoperative treatment effect of MG was similar between patients with and without new onset ADs (p > 0.05). CONCLUSIONS We observed a higher incidence rate of autoimmune diseases, especially rheumatoid arthritis, in MG patients after thymectomy. The most common types of ADs after thymectomy were different from those before thymectomy. New onset ADs tended to occur in female and young nonthymoma MG patients. The postoperative effect of MG was not related with the new occurrence of ADs.
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Affiliation(s)
- Wenxin Tian
- Department of Thoracic Surgery, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingP.R. China
| | - Jing He
- Department of Neurology, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingP.R. China
| | - Hanbo Yu
- Department of Thoracic Surgery, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingP.R. China
| | - Yaoguang Sun
- Department of Thoracic Surgery, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingP.R. China
| | - Qingjun Wu
- Department of Thoracic Surgery, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingP.R. China
| | - Peng Jiao
- Department of Thoracic Surgery, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingP.R. China
| | - Chao Ma
- Department of Thoracic Surgery, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingP.R. China
| | - Chuan Huang
- Department of Thoracic Surgery, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingP.R. China
| | - Donghang Li
- Department of Thoracic Surgery, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingP.R. China
| | - Hongfeng Tong
- Department of Thoracic Surgery, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingP.R. China
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Hashimoto Encephalopathy—Still More Questions than Answers. Cells 2022; 11:cells11182873. [PMID: 36139446 PMCID: PMC9496753 DOI: 10.3390/cells11182873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/05/2022] [Accepted: 09/12/2022] [Indexed: 12/03/2022] Open
Abstract
The normal function of the nervous system is conditioned by the undisturbed function of the thyroid gland and its hormones. Comprehensive clinical manifestations, including neurological disorders in Hashimoto’s thyroiditis, have long been understood and, in recent years, attention has been paid to neurological symptoms in euthyroid patients. Hashimoto encephalopathy is a controversial and poorly understood disease entity and the pathogenesis of the condition remains unclear. We still derive our understanding of this condition from case reports, but on the basis of these, a clear clinical picture of this entity can be proposed. Based on a review of the recent literature, the authors present the current view on the subject, discuss controversies and questions that still remain unanswered, as well as ongoing research in this area and the results of our own work in patients with Hashimoto’s thyroiditis.
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7
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Bi Z, Cao Y, Liu C, Gui M, Lin J, Zhang Q, Li Y, Ji S, Bu B. Remission and relapses of myasthenia gravis on long-term tacrolimus: a retrospective cross-sectional study of a Chinese cohort. Ther Adv Chronic Dis 2022; 13:20406223221122538. [PMID: 36093262 PMCID: PMC9459458 DOI: 10.1177/20406223221122538] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/02/2022] [Indexed: 11/23/2022] Open
Abstract
Objective: To identify the factors that predict the remission and relapses in myasthenia
gravis (MG) patients improved by prednisone and tacrolimus treatment. Methods: A retrospective, observational cohort analysis of MG patients who achieved
remission after receiving prednisone and tacrolimus were performed at Tongji
Hospital. The main outcome measures were the time to remission, prednisone
discontinuation, tacrolimus reduction–associated relapse, and treatment
outcome. Results: After adding tacrolimus, 256 patients were able to achieve remission with a
mean time to remission of 2.1 ± 1.4 months. After a median follow-up of
2.9 years, 167 patients (65.2%) discontinued prednisone, and 20 patients
(7.8%) achieved complete stable remission. Moreover, 53 of the 109 patients
who were tapering tacrolimus experienced relapses. In multivariable
analysis, female sex, low tacrolimus concentrations, and quantitative
myasthenia gravis (QMG) scores have a positive correlation with the time to
remission; concomitant additional autoimmune disease (AID) and high
anti-acetylcholine receptor antibody (AChR-ab) levels were significantly
associated with low probabilities of prednisone discontinuation [odds ratio
(OR) = 0.312–0.912, respectively]; rapid tacrolimus decrement speed
(⩾0.76 mg/year) was an independent predictor for the development of relapse
during tapering tacrolimus (OR = 5.662). Conclusion: Sex, tacrolimus concentrations, and QMG scores can be used as potential
predictors of the time to remission in MG patients treated with tacrolimus
and prednisone. Prednisone should be tapered slowly, especially in patients
with additional AID or high serum titers of AChR-ab. To avoid symptoms
recurrence, the dose of tacrolimus should reduce slowly, not exceeding
0.76 mg/year.
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Affiliation(s)
- Zhuajin Bi
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yayun Cao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Department of Radiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chenchen Liu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mengcui Gui
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Lin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qing Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suqiong Ji
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan 430030, Hubei Province, China
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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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Epidemiology of myasthenia gravis in the province of Ourense (Galicia, Spain). NEUROLOGÍA (ENGLISH EDITION) 2022; 38:75-81. [PMID: 35249845 DOI: 10.1016/j.nrleng.2020.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 06/12/2020] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune disease affecting nerve transmission at the level of the neuromuscular junction, and typically causes fluctuating muscle weakness. Epidemiological studies show an increase in MG prevalence, particularly among the older population. OBJECTIVE We performed a retrospective epidemiological study to determine the incidence and prevalence of MG in the province of Ourense (Galicia, Spain), characterised by population ageing. MATERIAL AND METHODS Patients were selected from our clinical neuromuscular diseases database by searching for patients with an active prescription for pyridostigmine bromide. Incidence was estimated for the period 2009-2018. We calculated prevalence at 31/12/2018. According to census data for the province of Ourense, the population on 1/1/2019 was 307 651, of whom 96 544 (31.4%) were aged ≥ 65 years. RESULTS We identified 80 cases of MG, with a prevalence rate of 260 cases/1 000 000 population (95% CI, 202.7-316.4), rising to 517.9/1 000 000 population in those aged ≥ 65 (95% CI, 363.2-672.9). Cumulative incidence in the study period was 15.4 cases per 1 000 000 person-years. Early onset (≤ 50 years) was recorded in 29.1% of cases. CONCLUSION The prevalence of MG in our health district is one of the highest published figures, and the disease is highly prevalent in the older population.
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Shi J, Huan X, Zhou L, Xi J, Song J, Wang Y, Luo S, Zhao C. Comorbid Autoimmune Diseases in Patients With Myasthenia Gravis: A Retrospective Cross-Sectional Study of a Chinese Cohort. Front Neurol 2021; 12:790941. [PMID: 34880829 PMCID: PMC8645996 DOI: 10.3389/fneur.2021.790941] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/01/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction: The phenomenon of coexisting autoimmune diseases (ADs) in patients with myasthenia gravis (MG) has attracted considerable attention. However, few studies have investigated the burden and potential clinical associations of ADs in Chinese MG cohorts. Methods: In this retrospective cross-sectional study, we reviewed the records of 1,132 patients with MG who were admitted to Huashan Hospital Fudan University from August 2013 to August 2020. Patients were excluded if they had incomplete medical records (n = 336). Results: Comorbid ADs were found in 92 of 796 Chinese patients with MG (11.6%), among which, hyperthyroidism (6.7%), hypothyrosis (2.6%), and vitiligo (0.8%) were predominant. Patients with MG with ADs were predominantly female, younger at the onset of MG symptoms, and had a lower frequency of thymoma. Compared to the general population, we found a significantly higher percentage of hyperthyroidism (8.5-fold increase, p < 0.001), hypothyrosis (2.6-fold increase, p < 0.001), vitiligo (1.3-fold increase, p < 0.001), rheumatoid arthritis (1.4-fold increase, p < 0.001), immune thrombocytopenic purpura (193.1-fold increase, p < 0.001), autoimmune hemolytic anemia (7.4-fold increase, p < 0.001), autoimmune hepatitis (5.1-fold increase, p < 0.001), and polymyositis (11.5-fold increase, p < 0.001) in patients with MG with ADs. Patients with MG with ADs presented a lower proportion of previous history of MC (0 vs. 5.6%, p < 0.05) than those without ADs. The proportion of MGFA Class I at onset in patients with MG with ADs was significantly higher than that in patients with MG without ADs (77.0 vs. 52.7%, p < 0.05). The proportion of MuSK-positive in patients with MG with ADs was significantly lower than that in patients with MG without ADs (0 vs. 4.8%, p < 0.05). Conclusion: In conclusion, we observed a higher frequency of concurrent ADs in a Chinese MG cohort. Furthermore, MG combined with ADs tended to have mild clinical presentation.
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Affiliation(s)
- Jianquan Shi
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiao Huan
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Lei Zhou
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Jie Song
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Ying Wang
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
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11
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Rotondo Dottore G, Leo M, Ricciardi R, Maestri M, Bucci I, Lucchi M, Melfi F, Guida M, De Rosa A, Petrucci L, Ionni I, Lanzolla G, Nicolì F, Mantuano M, Ricci D, Latrofa F, Mariotti S, Marcocci C, Marinò M. Disappearance of Anti-Thyroid Autoantibodies following Thymectomy in Patients with Myasthenia Gravis. Eur Thyroid J 2021; 10:237-247. [PMID: 34178710 PMCID: PMC8216016 DOI: 10.1159/000510701] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/04/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES The thymus plays a central role in immune tolerance, which prevents autoimmunity. Myasthenia gravis (MG) is commonly associated with thymoma or thymus hyperplasia, and it can coexist with autoimmune thyroid diseases. However, the role of the thymus in thyroid autoimmunity remains to be clarified, which we investigated here. STUDY DESIGN The study design entailed the inclusion of consecutive MG patients and the measurement of anti-thyroid autoantibodies at baseline and, limited to autoantibody-positive patients, also at 24 and 48 weeks. One hundred and seven MG patients were studied. The main outcome measure was the behaviour of anti-thyroglobulin autoantibodies (TgAbs) and anti-thyroperoxidase autoantibodies (TPOAbs) over time in relation to thymectomy. RESULTS Serum TgAbs and/or TPOAbs were detected in ∼20% of patients in the absence of thyroid dysfunction. The prevalence of positive serum TgAbs and/or TPOAbs decreased significantly (p = 0.002) over the follow-up period in patients who underwent thymectomy, but not in patients who were not thymectomized. When the analysis was restricted to TgAbs or TPOAbs, findings were similar. On the same line, there was a general trend towards a reduction in the serum concentrations of anti-thyroid autoantibodies in patients who underwent thymectomy, which was significant for TPOAbs (p = 0.009). CONCLUSIONS Our findings suggest a role of the thymus in the maintenance of humoral thyroid autoimmunity.
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Affiliation(s)
- Giovanna Rotondo Dottore
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Marenza Leo
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Roberta Ricciardi
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa and University Hospital of Pisa, Pisa, Italy
- Department of Surgical, Medical and Molecular Pathology, Division of Thoracic Surgery, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Michelangelo Maestri
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Ilaria Bucci
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Marco Lucchi
- Department of Surgical, Medical and Molecular Pathology, Division of Thoracic Surgery, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Franca Melfi
- Department of Surgical, Medical and Molecular Pathology, Division of Thoracic Surgery, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Melania Guida
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Anna De Rosa
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Loredana Petrucci
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Ilaria Ionni
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Giulia Lanzolla
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Francesca Nicolì
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Michele Mantuano
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Debora Ricci
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Francesco Latrofa
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Stefano Mariotti
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Michele Marinò
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
- *Michele Marinò, Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Via Paradisa 2, IT–56124 Pisa (Italy),
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García Estévez DA, López Díaz LM, Pardo Parrado M, Pérez Lorenzo G, Sabbagh Casado NA, Ozaita Arteche G, Rodríguez Gómez D. Epidemiology of myasthenia gravis in the province of Ourense (Galicia, Spain). Neurologia 2020; 38:S0213-4853(20)30215-2. [PMID: 32900528 DOI: 10.1016/j.nrl.2020.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 05/24/2020] [Accepted: 06/12/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune disease affecting nerve transmission at the level of the neuromuscular junction, and typically causes fluctuating muscle weakness. Epidemiological studies show an increase in MG prevalence, particularly among the older population. OBJECTIVE We performed a retrospective epidemiological study to determine the incidence and prevalence of MG in the province of Ourense (Galicia, Spain), characterised by population ageing. MATERIAL AND METHODS Patients were selected from our clinical neuromuscular diseases database by searching for patients with an active prescription for pyridostigmine bromide. Incidence was estimated for the period 2009-2018. We calculated prevalence at 31/12/2018. According to census data for the province of Ourense, the population on 1/1/2019 was 307,651, of whom 96,544 (31.4%) were aged ≥ 65 years. RESULTS We identified 80 cases of MG, with a prevalence rate of 260 cases/1 000 000 population (95% CI, 202.7-316.4), rising to 517.9/1 000 000 population in those aged ≥ 65 (95% CI, 363.2-672.9). Cumulative incidence in the study period was 15.4 cases per 1 000 000 person-years. Early onset (≤ 50 years) was recorded in 29.1% of cases. CONCLUSION The prevalence of MG in our health district is one of the highest published figures, and the disease is highly prevalent in the older population.
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Affiliation(s)
- D A García Estévez
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España.
| | - L M López Díaz
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
| | - M Pardo Parrado
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
| | - G Pérez Lorenzo
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
| | - N A Sabbagh Casado
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
| | - G Ozaita Arteche
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
| | - D Rodríguez Gómez
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
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Concurrence of Myasthenia Gravis and Thyroid Disorders: A Retrospective Database Study. J ASEAN Fed Endocr Soc 2019; 34:153-157. [PMID: 33442150 PMCID: PMC7784156 DOI: 10.15605/jafes.034.02.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/16/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Both myasthenia gravis (MG) and autoimmune thyroid diseases (AITDs) are autoimmune diseases. Graves’disease (GD) is the most common AITD reported to be associated with MG. Currently, there is limited data on prevalence and clinical features/outcomes of MG in various thyroid diseases in a large database report. Methodology A total of 872 patients with MG and 97,251 patients with thyroid disorders had been recorded by the tertiary hospital database. The study period was between 1997 and 2017. Patients with a thyroid disorder and MG were identified by the ICD-10-CM code. Clinical courses of MG accompanied by thyroid disorders were studied. Results During the 20-year study period, there were 872 patients with MG and 97,251 patients with thyroid disorders. In the group with thyroid disorders, 28,886 patients (29.70%) had GD, 1,612 patients (1.66%) had Hashimoto's thyroiditis (HT), 13,172 patients (13.54%) had toxic goiter and 53,581 patients (55.10%) had nontoxic goiter. Ninety-seven patients had been diagnosed with both MG and thyroid disorders. Among the four types of thyroid disorders, the rate of MG was highest in HT group (9.92/1,000 HT patients). There were four significant factors among four groups of thyroid disorders including age of onset of thyroid disease (p 0.004), MG classification (p<0.001), MG treatment (p<0.001), and thymic pathology (p 0.034). Among the four groups of thyroid disorders, patients with MG and HT were diagnosed with thyroid disease at the youngest age (27 years) compared with other thyroid diseases. Additionally, the MG patients with HT also had the highest proportion of MG class 4-5 a/b (7 patients, 43.75%), received prednisolone treatment (15 patients, 93.75%), received immunosuppressants (9 patients, 56.25%), received IVIG or PLEX (5 patients, 31.30%), and had thymoma (6 patients, 46.15%). Conclusion MG is most prevalent in patients with HT. Patients with both MG and HT had more severe MG status and had higher rate of thymoma.
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Song RH, Yao QM, Wang B, Li Q, Jia X, Zhang JA. Thyroid disorders in patients with myasthenia gravis: A systematic review and meta-analysis. Autoimmun Rev 2019; 18:102368. [DOI: 10.1016/j.autrev.2019.102368] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 04/24/2019] [Indexed: 01/23/2023]
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15
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Chou CC, Su IC, Chou IJ, Lin JJ, Lan SY, Wang YS, Kong SS, Chen YJ, Hsieh MY, Hung PC, Wang HS, Chou ML, Lin KL. Correlation of anti-acetylcholine receptor antibody levels and long-term outcomes of juvenile myasthenia gravis in Taiwan: a case control study. BMC Neurol 2019; 19:170. [PMID: 31319795 PMCID: PMC6637626 DOI: 10.1186/s12883-019-1397-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 07/08/2019] [Indexed: 12/19/2022] Open
Abstract
Background Myasthenia gravis is the most common disease affecting the neuromuscular junction. The most common etiology among patients with juvenile myasthenia gravis is the production of antibodies against the acetylcholine receptor. However, the clinical outcome in relation to serum levels of anti-acetylcholine receptor antibodies in juvenile myasthenia gravis has rarely been discussed. We aimed to analyze the correlation between the presence of anti-acetylcholine receptor antibodies and outcome in juvenile myasthenia gravis. Methods Patients diagnosed with juvenile myasthenia gravis younger than of 20 years of age were retrospectively recruited from January 1995 to February 2017 in a tertiary referral medical center. According to the Myasthenia Gravis Foundation of America outcome scale, the primary outcome was complete symptom remission and cessation of medications for at least 1 year measured 2 years after diagnosis. Secondary outcome was complete symptom remission at the last outpatient clinic. Results A total of 54 patients were followed up for over 2 years. Nine patients (9/54, 16.7%) achieved complete remission without medication use at 2 years after diagnosis. Thirteen (24.1%) patients achieved complete remission during longer follow-up periods. Those with negative anti-acetylcholine receptor antibodies were more likely to achieve complete remission at 2 years (6/15 [40%] vs. 3/39 [7.7%], 95% Confidence interval [CI] 1.670 to 38.323) and at the last outpatient clinic follow-up (8/15 [53.3%] vs. 5/39 [12.8%], 95% CI 2.367 to 20.704). Thirteen patients with comorbid autoimmune thyroid diseases were older than those without disease (11.8 ± 5.8 years old vs. 8.0 ± 6.3 years old, 95% CI 0.018 to 7.33). Moreover, patients negative for anti-acetylcholine receptor antibodies were less likely comorbid with autoimmune thyroid disease (1/35 [2.9%] vs. 12/71 [16.9%], 95% CI 0.018 to 1.161). Conclusions Juvenile myasthenia gravis patients without anti-acetylcholine antibodies exhibited significantly increased complete remission rates and a reduced likelihood of comorbid autoimmune thyroid diseases compared with those with anti-acetylcholine receptor antibodies among Chinese. Electronic supplementary material The online version of this article (10.1186/s12883-019-1397-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cheng-Che Chou
- Division of Paediatrics, Keelung Chang Gung Memorial Hospital, 222, Maijin Road, Keelung, Taiwan
| | - I-Chen Su
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - I-Jun Chou
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.,Division of Paediatrics, Neurocritical Care Centre, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shih-Yun Lan
- Division of Paediatrics, Saint Paul Hospital, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Yi-Shan Wang
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Shu-Sing Kong
- Division of Paediatrics, Taipei Medical University Shuang Ho Hospital, Zhonghe Dist., New Taipei City, Taiwan
| | - Yun-Ju Chen
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Meng-Ying Hsieh
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Po-Cheng Hung
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Min-Liang Chou
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.
| | - Kuang-Lin Lin
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.
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Alekseeva TM, Kreis OA, Gavrilov YV, Valko PO, Weber KP, Valko Y. Impact of autoimmune comorbidity on fatigue, sleepiness and mood in myasthenia gravis. J Neurol 2019; 266:2027-2034. [PMID: 31115673 DOI: 10.1007/s00415-019-09374-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/01/2019] [Accepted: 05/08/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Disease burden in myasthenia gravis (MG) and in other autoimmune disorders is often determined by common accompanying symptoms such as fatigue, sleepiness and mood disturbances. Many MG patients have a second autoimmune disease, but it is unclear whether autoimmune comorbidities add to the severity of fatigue, sleepiness and mood disturbances. METHODS We ascertained the presence of autoimmune comorbidities in 69 well-characterized MG patients. To assess fatigue, sleepiness and mood disturbances, we applied the Fatigue Severity Scale (FSS), the Fatigue Impact Scale (FIS), the Epworth Sleepiness Scale (ESS), as well as the Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) to all patients. RESULTS Thirteen MG patients had concomitant autoimmune thyroid disease (AITD), including 1 patient with rheumatoid arthritis as third autoimmune disease. Fatigue (68.1%), excessive daytime sleepiness (14.5%), moderate-severe depression (20.3%) and anxiety (26.1%) were common, but MG patients with and without autoimmune comorbidities had similar FSS, FIS, ESS, BDI and STAI scores. The presence of autoimmune comorbidities was not associated with altered clinical and immunological MG characteristics, but MG patients with autoimmune comorbidities have more often been treated with corticosteroids than patients without autoimmune comorbidities (92.3% vs. 60.7%; p = 0.03). CONCLUSIONS While many MG patients were affected by fatigue, sleepiness, depression and anxiety, the present study does not suggest that coexisting autoimmune diseases substantially contribute to the magnitude of these cumbersome comorbid symptoms. However, the higher frequency of steroid treatment may have counterbalanced the effects of the autoimmune comorbidity.
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Affiliation(s)
- T M Alekseeva
- Department of Neurology and Psychiatry, Almazov National Medical Research Centre, 197341, St. Petersburg, Russia
| | - O A Kreis
- Department of Neurology, North-Western State Medical University, 191015, St. Petersburg, Russia
| | - Y V Gavrilov
- Department of General Pathology and Pathological Physiology, Institute of Experimental Medicine, St. Petersburg, Russia
| | - P O Valko
- Department of Neurology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland
| | - K P Weber
- Department of Neurology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland.,Department of Ophthalmology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland
| | - Yulia Valko
- Department of Neurology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland.
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Shi TY, Wen XH, Shi XH, Lu YW. Thymic epithelial tumor complicated by immunological abnormalities: results from a single-center retrospective study in China. J Thorac Dis 2019; 11:1580-1588. [PMID: 31179102 DOI: 10.21037/jtd.2019.02.90] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To describe the clinical manifestations, immunological features, treatments, and outcomes of patients with thymic epithelial tumor (TET) complicated by immunological abnormalities, and to improve knowledge on immunological abnormalities in this rare disease. Methods Patients with pathologically confirmed TET at Beijing Chaoyang Hospital between January 2013 and May 2018 were included in this study, and clinical data were analyzed retrospectively. Immunological abnormalities were classified into two groups as follows: Good syndrome (GS) and autoimmune disease (AD). Results Fifty-nine TET patients were enrolled; twenty-two patients (37.3%) had immune dysfunction. There were no gender, age, or histological type differences between groups with or without immunological abnormalities. Six patients had GS, of whom four patients were diagnosed after thymectomy. Recurrent respiratory infections, particularly opportunistic infections, were the most common manifestation. Three GS patients developed a second cancer (50%; P=0.011). Anti-infective therapy and immunoglobulin supplements effectively treated GS. Seventeen patients developed ADs, including myasthenia gravis (MG) (n=13), Hashimoto's thyroiditis (n=4), Sjogren's syndrome (n=1), rheumatoid arthritis (n=1), pemphigus (n=1), and Evans syndrome (n=1). One patient developed both MG and GS and 4 patients presented with two ADs. Three AD cases occurred after thymectomy. Pemphigus and 80% (8/10) of MG cases were resolved following thymectomy. Conclusions There is a strong association between immunological abnormalities and TET, which may present at any time point during the disease, even after thymectomy. In addition to infection, GS patients are more likely to develop a second cancer. Thymectomy may produce favorable outcomes for MG in this study, while surgery does not improve immunodeficiency in GS patients.
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Affiliation(s)
- Tian-Yan Shi
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Xiao-Hong Wen
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Xu-Hua Shi
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Yue-Wu Lu
- Department of Rheumatology and Clinical Immunology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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Tanovska N, Novotni G, Sazdova-Burneska S, Kuzmanovski I, Boshkovski B, Kondov G, Jovanovski-Srceva M, Kokareva A, Isjanovska R. Myasthenia Gravis and Associated Diseases. Open Access Maced J Med Sci 2018; 6:472-478. [PMID: 29610603 PMCID: PMC5874368 DOI: 10.3889/oamjms.2018.110] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/03/2018] [Accepted: 02/04/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND: Myasthenia gravis (MG) is an autoimmune disease caused by the action of specific antibodies to the postsynaptic membrane of the neuromuscular junction, leading to impaired neuromuscular transmission. Patients with MG have an increased incidence of other autoimmune diseases. AIM: to determine the presence of other associated diseases in patients with MG. METHOD: A group of 127 patients with MG followed in 10 years period, in which the presence of other associated diseases has been analysed. RESULTS: The sex ratio is in favour of the female sex, the average age of the initial manifestation of the disease is less than 50 years, 65.4% of the patients with MG have another disease. 15.0% patients have associated another autoimmune disease. Thyroid disease is the most common associated with MG, rarely rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and other autoimmune diseases. Other diseases include hypertension, heart disease, diabetes, respiratory diseases, dyslipidemia. 10.2% of the patients are diagnosed with extrathymic tumours of various origins. CONCLUSION: Associated diseases are common in patients with MG, drawing attention to the possible common basis for their coexistence, as well as their impact on the intensity and treatment of the disease.
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Affiliation(s)
- Nikolina Tanovska
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Gabriela Novotni
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Slobodanka Sazdova-Burneska
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Igor Kuzmanovski
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Bojan Boshkovski
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Goran Kondov
- University Clinic for Thoracic and Vascular Surgery, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Marija Jovanovski-Srceva
- University Clinic for Anesthesia and Reanimation, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Anita Kokareva
- University Clinic for Anesthesia and Reanimation, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Rozalinda Isjanovska
- Institute for Epidemiology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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Horiuchi K, Nagai A, Wakita M, Ito S, Takamura K, Houzen H. Myasthenic Crisis Complicated with Myxedema, Positive for Both Anti-acetylcholine Receptor and Anti-muscle-specific Tyrosine Kinase Antibodies. Intern Med 2018; 57:265-268. [PMID: 29093409 PMCID: PMC5820048 DOI: 10.2169/internalmedicine.9291-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We herein report the case of myasthenic crisis occurring in a 51-year-old man. He had experienced ptosis, increased body weight with edema, and fatigue with dyspnea. He presented at our emergency department with disturbed consciousness. He was originally diagnosed with myxedema coma, and he required artificial respiration. Because his weakness persisted and he was positive for anti-acetylcholine receptor antibodies and anti-muscle-specific tyrosine kinase antibodies, we diagnosed myasthenic crisis after various examinations. His clinical response to treatment was good and he was discharged in an ambulatory status 3 months after admission. This case demonstrates that myasthenic crisis may occur in association with myxedema.
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Affiliation(s)
| | - Azusa Nagai
- Department of Neurology, Obihiro Kosei General Hospital, Japan
| | - Masahiro Wakita
- Department of Neurology, Obihiro Kosei General Hospital, Japan
| | - Shotaro Ito
- First Department of Medicine, Obihiro Kosei General Hospital, Japan
| | - Kei Takamura
- First Department of Medicine, Obihiro Kosei General Hospital, Japan
| | - Hideki Houzen
- Department of Neurology, Obihiro Kosei General Hospital, Japan
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Cordts I, Bodart N, Hartmann K, Karagiorgou K, Tzartos JS, Mei L, Reimann J, Van Damme P, Rivner MH, Vigneron A, Weis J, Schulz JB, Tzartos SJ, Claeys KG. Screening for lipoprotein receptor-related protein 4-, agrin-, and titin-antibodies and exploring the autoimmune spectrum in myasthenia gravis. J Neurol 2017; 264:1193-1203. [DOI: 10.1007/s00415-017-8514-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/24/2017] [Accepted: 05/08/2017] [Indexed: 01/09/2023]
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Lin YP, Iqbal U, Nguyen PA, Islam MM, Atique S, Jian WS, Li YCJ, Huang CL, Hsu CH. The Concomitant Association of Thyroid Disorders and Myasthenia Gravis. Transl Neurosci 2017; 8:27-30. [PMID: 28729915 PMCID: PMC5443889 DOI: 10.1515/tnsci-2017-0006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/31/2017] [Indexed: 11/23/2022] Open
Abstract
Background Some of the thyroid disorders (TD) and Myasthenia gravis (MG) are autoimmune related disease. The purpose of the study to evaluate the relationship of MG with all morphological and functional thyroid disorders. Methods We constructed a population-based cohort study during the period from January 2000-December 2002 by using reimbursement data from the Bureau National Health Insurance (NHI) system in Taiwan. Patients with TD and MG were identified by referring to the ICD-9-CM codes. (ICD-10-CM as reference) .The association of TD with MG occurred only in the same person within the study period. The Q value was used to measure the strength of disease-disease associations. Results We obtained 520628 TD and 7965 MG records for analysis. Diffuse toxic goiter had highest association rate, followed by nontoxic nodular goiter, simple goiter, chronic lymphocytic thyroiditis, thyroid cancer, and toxic nodular goiter. Female and older patients had a higher rate than their male and younger counterparts, respectively. Functional abnormalities revealed higher incidence of thyrotoxicosis and hypothyroidism in both sexes. We also found the strongest association in men with chronic thyroiditis, diffuse toxic goiter, thyrotoxicosis, acquired hypothyroidism, thyroid cancer, and simple goiter. While an intermediate association was observed in female with diffuse toxic goiter, in a male with toxic and nontoxic nodular/multinodular goiters, in female with thyrotoxicosis, thyroid cancer and acquired hypothyroidism. Conclusion This population based cohort study showed potential association of all types of TD with MG, and observed a higher association rate in female autoimmune TD whereas males showed a higher strength of association.
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Affiliation(s)
- Yu-Pei Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Usman Iqbal
- Masters Program in Global Health & Development Dept., College of Public Health, Taipei Medical University, Taipei, Taiwan.,International Center for Health Information Technology, Taipei, Taiwan
| | - Phung-Anh Nguyen
- International Center for Health Information Technology, Taipei, Taiwan.,Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Md Mohaimenul Islam
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Suleman Atique
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Wen-Shan Jian
- International Center for Health Information Technology, Taipei, Taiwan.,School of Health Care Administration, Taipei Medical University, Taipei, Taiwan.,Faculty of Health Sciences, Macau University of Science and Technology, Macau, China
| | - Yu-Chuan Jack Li
- International Center for Health Information Technology, Taipei, Taiwan.,Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.,Chair, Department of Dermatology, Wan Fang Hospital, Taipei, Taiwan
| | - Chen-Ling Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chung-Huei Hsu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan.,Department of Nuclear Medicine, Taipei Medical University Hospital, Taipei, Taiwan
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22
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Abstract
The association between thymoma and autoimmunity is well known. Besides myasthenia gravis, which is found in 15 to 20% of patients with thymoma, other autoimmune diseases have been reported: erythroblastopenia, systemic lupus erythematosus, inflammatory myopathies, thyroid disorders, Isaac's syndrome or Good's syndrome. More anecdotally, Morvan's syndrome, limbic encephalitis, other autoimmune cytopenias, autoimmune hepatitis, and bullous skin diseases (pemphigus, lichen) have been reported. Autoimmune diseases occur most often before thymectomy, but they can be discovered at the time of surgery or later. Two situations require the systematic investigation of a thymoma: the occurrence of myasthenia gravis or autoimmune erythroblastopenia. Nevertheless, the late onset of systemic lupus erythematosus or the association of several autoimmune manifestations should lead to look for a thymoma. Neither the characteristics of the patients nor the pathological data can predict the occurrence of an autoimmune disease after thymectomy. Thus, thymectomy usefulness in the course of the autoimmune disease, except myasthenia gravis, has not been demonstrated. This seems to indicate the preponderant role of self-reactive T lymphocytes distributed in the peripheral immune system prior to surgery. Given the high infectious morbidity in patients with thymoma, immunoglobulin replacement therapy should be considered in patients with hypogammaglobulinemia who receive immunosuppressive therapy, even in the absence of prior infection.
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23
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Kubiszewska J, Szyluk B, Szczudlik P, Bartoszewicz Z, Dutkiewicz M, Bielecki M, Bednarczuk T, Kostera-Pruszczyk A. Prevalence and impact of autoimmune thyroid disease on myasthenia gravis course. Brain Behav 2016; 6:e00537. [PMID: 27781146 PMCID: PMC5064344 DOI: 10.1002/brb3.537] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/12/2016] [Accepted: 06/21/2016] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Autoimmune thyroid diseases (ATDs) frequently accompany myasthenia gravis (MG) and may influence its course. We aimed to determine the association and impact of ATD with early- (<50 years), late-onset MG, or thymoma-MG. MATERIALS AND METHODS Prevalence of ATD was measured in a cross-sectional study of 343 consecutive patients with MG (236 F, 107 M) aged 4-89 years; 83.8% were seropositive, in 2.9%, anti-MuSK antibodies were detected. Concentrations of antithyroid peroxidase antibodies, antithyroglobulin antibodies, antithyrotropin receptor antibodies, and TSH level were measured in all patients. MG clinical course, treatment received, and treatment results were evaluated. RESULTS Autoimmune thyroid diseases were diagnosed in 92 (26.8%) of MG patients including 4.4% with Graves (GD), 9% with Hashimoto thyroiditis (HT), and 13.4% with antithyroid antibodies only. GD patients had ocular symptoms more often than patients with antithyroid antibodies or HT (p = .008). ATD prevalence was comparable in MG with early and late onset, while non-ATDs were more frequent in thymoma-MG (p = .049). Immunosuppressive therapy was less frequently needed in the patients with MG and ATD, indirectly indicating milder MG course (p = .005). Risk of myasthenic crisis and the results of treatment did not differ between patients with and without ATD. CONCLUSIONS Autoimmune thyroid diseases are frequently accompanied by early-and late-onset MG, while thymoma-MG is related to higher risk of non-ATD. Myasthenia coexisting with ATD follows milder course than MG alone.
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Affiliation(s)
| | - Beata Szyluk
- Department of Neurology Medical University of Warsaw Warsaw Poland
| | - Piotr Szczudlik
- Department of Neurology Medical University of Warsaw Warsaw Poland
| | - Zbigniew Bartoszewicz
- Department of Internal Medicine and Endocrinology Medical University of Warsaw Warsaw Poland
| | - Małgorzata Dutkiewicz
- Department of Immunology, Biochemistry and Nutrition Medical University of Warsaw Warsaw Poland
| | - Maksymilian Bielecki
- Department of Psychology SWPS University of Social Sciences and Humanities Warsaw Poland
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology Medical University of Warsaw Warsaw Poland
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24
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Bernard C, Frih H, Pasquet F, Kerever S, Jamilloux Y, Tronc F, Guibert B, Isaac S, Devouassoux M, Chalabreysse L, Broussolle C, Petiot P, Girard N, Sève P. Thymoma associated with autoimmune diseases: 85 cases and literature review. Autoimmun Rev 2016; 15:82-92. [DOI: 10.1016/j.autrev.2015.09.005] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 09/20/2015] [Indexed: 11/30/2022]
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25
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Fang F, Sveinsson O, Thormar G, Granqvist M, Askling J, Lundberg IE, Ye W, Hammarström L, Pirskanen R, Piehl F. The autoimmune spectrum of myasthenia gravis: a Swedish population-based study. J Intern Med 2015; 277:594-604. [PMID: 25251578 DOI: 10.1111/joim.12310] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To determine the prevalence of myasthenia gravis (MG) and the rate of concurrent autoimmune diseases in patients with MG. DESIGN AND SETTING Using the Swedish health and population registers, during the period 2005-2010, we conducted a nested case-control study of patients with MG (n = 2045) with five age- and sex-matched population-based controls per case. Register-based MG diagnosis was validated against the Stockholm MG Cohort. Similar nested case-control studies were conducted in patients with multiple sclerosis (MS), as a neuroinflammatory disease control, and siblings of patients with MG. MAIN OUTCOME MEASURE Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated as a measure of the association between MG and other autoimmune diseases. RESULTS The prevalence of MG was 24.8/100,000, and patients with MG had an increased risk of another autoimmune disease compared to controls (22.0% vs. 8.9%; OR: 2.82, 95% CI: 2.49-3.20); this risk was stronger amongst younger persons and women. Polymyositis/dermatomyositis, systemic lupus erythematosus and Addison's disease, three conditions regulated by the HLA-B8-DR3 haplotype, were most strongly associated with MG, especially early-onset disease. HLA typing in the Stockholm MG Cohort showed that early-onset MG was indeed dominated by HLA-B8-DR3. The risk of another autoimmune disease was increased in both patients with MS and siblings of patients with MG, compared to their respective controls, but to a lesser extent than in patients with MG. CONCLUSIONS Our results suggest that MG shares risk factors with other autoimmune diseases, to a greater degree than MS, with a particular role of the HLA-B8-DR3 haplotype, especially amongst younger and female patients.
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Affiliation(s)
- F Fang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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26
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Nacu A, Andersen JB, Lisnic V, Owe JF, Gilhus NE. Complicating autoimmune diseases in myasthenia gravis: a review. Autoimmunity 2015; 48:362-8. [PMID: 25915571 PMCID: PMC4616023 DOI: 10.3109/08916934.2015.1030614] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Myasthenia gravis (MG) is a rare autoimmune disease of skeletal muscle endplates. MG subgroup is relevant for comorbidity, but usually not accounted for. MG patients have an increased risk for complicating autoimmune diseases, most commonly autoimmune thyroid disease, systemic lupus erythematosus and rheumatoid arthritis. In this review, we present concomitant autoimmune disorders associated with the different MG subgroups, and show how this influences treatment and prognosis. Concomitant MG should always be considered in patients with an autoimmune disorder and developing new neuromuscular weakness, fatigue or respiratory failure. When a second autoimmune disorder is suspected, MG should be included as a differential diagnosis.
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Affiliation(s)
- Aliona Nacu
- a Department of Neurology , Haukeland University Hospital , Bergen , Norway
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27
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Evoli A, Caliandro P, Iorio R, Alboini PE, Damato V, LaTorre G, Provenzano C, Marino M, Lauriola L, Scuderi F, Bartoccioni E. Poly-autoimmunity in patients with myasthenia gravis: A single-center experience. Autoimmunity 2015; 48:412-7. [PMID: 25868386 DOI: 10.3109/08916934.2015.1031890] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We evaluated the co-occurrence of autoimmune diseases (ADs) in a large population of myasthenia gravis (MG) patients from a single center. Our survey included 984 patients, 904 with anti-acetylcholine receptor antibodies and 80 with anti-muscle specific kinase antibodies. The anti-acetylcholine receptor positive population included patients with early-onset (age at onset ≤ 50 years), late-onset and thymoma-associated disease. Follow-up ranged 2-40 years. Two-hundred and fourteen ADs were diagnosed in 185 patients; 26 of them had two or more ADs in association with MG. Thyroid disorders were the most common and, together with vitiligo and thrombocytopenia, occurred in all disease subsets. Otherwise, there was a broad variability with partial overlap among patient groups. The highest rate of ADs was observed in early-onset patients, while clusters, i.e. 2 or more ADs other than MG in the same individual, were more common among thymoma cases. Thirty-four diseases were diagnosed at the same time, 88 occurred before and 92 after the onset of MG. On multivariate analysis, immunosuppressive treatment was the only independent variable which negatively influenced the risk of developing other ADs in our cohort.
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Affiliation(s)
- Amelia Evoli
- a Institute of Neurology, Catholic University , Rome , Italy
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28
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Abstract
PURPOSE OF REVIEW This article provides an overview of the neurologic complications found in the various endocrine disorders affecting adult patients. Specifically, disorders in pituitary hormones (prolactin, growth hormone, vasopressin, and oxytocin), thyroid hormones, adrenal hormones (glucocorticoids), and sex hormones (estrogen and testosterone) will be covered, with an emphasis on identifying the signs and symptoms in addition to diagnosing and managing these disorders. RECENT FINDINGS Hyperthyroidism in the young was found to increase the risk for ischemic stroke in a recent prospective case-cohort study. The cognitive effects of hormonal therapy in postmenopausal women remain controversial, but a recent study found no benefit or risk in cognitive function when treating younger (50 to 55 years of age) postmenopausal women with hormonal therapy. SUMMARY Endocrine disorders can cause various neurologic complications, from insidious myopathy to acute encephalopathy. Diagnosing the endocrine disorder as the cause of the neurologic impairment is essential, as treating the underlying hormonal dysfunction will often rapidly reverse the neurologic symptoms. Ongoing research is needed to further clarify the role of hormonal dysfunction in neurologic disorders.
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29
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Nakata R, Motomura M, Masuda T, Shiraishi H, Tokuda M, Fukuda T, Ando T, Yoshimura T, Tsujihata M, Kawakami A. Thymus histology and concomitant autoimmune diseases in Japanese patients with muscle-specific receptor tyrosine kinase-antibody-positive myasthenia gravis. Eur J Neurol 2013; 20:1272-6. [PMID: 23679930 DOI: 10.1111/ene.12169] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 03/11/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE The differences in the characteristics of thymus histology, coexisting autoimmune diseases and related autoantibodies between anti-muscle-specific receptor tyrosine kinase (MuSK)-antibody (Ab)-positive myasthenia gravis (MG) patients, and anti-acetylcholine receptor (AChR)-Ab-positive MG patients are not clearly defined. METHODS The types of thymus histology, coexisting autoimmune diseases and associated Abs in 83 MuSK-Ab-positive patients nationwide were investigated and were compared with those in AChR-Ab-positive patients followed at our institute (n = 83). As for the autoantibodies associated with thymoma, titin Abs were measured. RESULTS Thymoma was not present in any of the MuSK-Ab-positive patients but presented in 21 patients (25.3%) amongst the AChR-Ab-positive patients. Titin Abs were absent in MuSK-Ab-positive patients but positive in 25 (30.1%) of the AChR-Ab-positive patients. Concomitant autoimmune diseases were present in eight MuSK-Ab-positive patients (9.6%) amongst whom Hashimoto's thyroiditis and rheumatoid arthritis predominated, whereas 22 AChR-Ab-positive patients (26.5%) had one or more concomitant autoimmune diseases of which Graves' disease predominated. CONCLUSIONS Differences in frequency of thymoma and thymic hyperplasia, coexisting autoimmune diseases and autoantibody positivity between MuSK-Ab-positive and AChR-Ab-positive MG were indicated, suggesting that, in contrast with AChR-Ab-positive MG, thymus does not seem to be involved in the pathogenic mechanisms of MuSK-Ab-positive MG.
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Affiliation(s)
- R Nakata
- Department of Clinical Neuroscience and Neurology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
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30
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Chen YL, Yeh JH, Chiu HC. Clinical features of myasthenia gravis patients with autoimmune thyroid disease in Taiwan. Acta Neurol Scand 2013; 127:170-4. [PMID: 22725712 DOI: 10.1111/j.1600-0404.2012.01693.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to analyze the prevalence and clinical features of myasthenia gravis (MG) patients with and without autoimmune thyroid disease (ATD). MATERIALS AND METHODS Between 1999 and 2009, we reviewed a total of 1482 patients with MG. On the basis of thyroid evaluations, as well as neurological, clinical, and serological findings, the patients were divided into group A (MG patients with ATD) or group B (MG patients without ATD). The patients were categorized as having ocular myasthenia when symptoms restricted to the ocular system were present for 2 years or more. RESULTS Of the 1482 MG patients, 121 (8.2%) patients were classified into group A. Graves' disease was more predominant (5.7%) than Hashimoto's thyroiditis (1.1%) and antibody-positive thyroid disease (1.4%). MG patients with ATD were predominantly female, were younger at the onset of MG symptoms, had a higher frequency of mild MG (ocular and mild generalized MG) and thymic hyperplasia, and had lower levels of seropositive anti-acetylcholine receptor antibodies. Compared to patients without thyroid eye disease, ATD patients with thyroid eye disease had a higher frequency of ocular MG. CONCLUSIONS This is the largest review of the clinical features of MG patients with and without ATD to date. We found that compared to ocular MG, mild MG is more commonly associated with ATD. Furthermore, we observed that thymic hyperplasia is more common in MG patients with ATD, while thymoma is more common in MG patients without ATD.
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Affiliation(s)
- Y.-L. Chen
- Division of Endocrinology, Department of Internal Medicine; Shin Kong Wu Ho-Su Memorial Hospital; Taipei; Taiwan
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31
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Maamar M, Tazi-Mezalek Z, Harmouche H, Charradi H, Adnaoui M, Aouni M. Myasthénie associée à une maladie de Biermer. Presse Med 2013; 42:230-2. [DOI: 10.1016/j.lpm.2012.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 02/15/2012] [Accepted: 02/21/2012] [Indexed: 10/28/2022] Open
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Lorenzoni PJ, Scola RH, Kay CSK, Muzzillo DA, Werneck LC. Coexistence of primary sclerosing cholangitis in a patient with myasthenia gravis. Ann Indian Acad Neurol 2012; 14:316-8. [PMID: 22346028 PMCID: PMC3271478 DOI: 10.4103/0972-2327.91966] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Revised: 06/23/2010] [Accepted: 09/21/2010] [Indexed: 12/18/2022] Open
Abstract
Myasthenia gravis (MG) is an immune-mediated disease that compromises the postsynaptic membrane of the neuromuscular junction. Primary sclerosing cholangitis (PSC) is considered an immune-mediated cholestatic liver disease. Both MG and PSC include an autoimmune pathogenesis, so there is some evidence that patients with MG or PSC have a higher risk of developing autoantibodies and other immune disorders than normal controls, but the coexistence of these two disorders has never been documented. We report a 40-year-old woman who presented with MG when she was 20 years old and developed PSC 20 years after a thymectomy. Liver biochemistry revealed cholestasis. Magnetic resonance imaging showed multifocal strictures and beads involving the intrahepatic bile ducts. A liver biopsy confirmed sclerosing cholangitis. Serological analysis demonstrated positive autoantibodies (Anti-nuclear antibodies, anti-smooth muscle antibodies). Repetitive stimulation had a decremental response, and antibodies to acetylcholine receptors were detectable. To our knowledge, this is the first case of PSC in a patient with MG. The main characteristics of both MG and PSC combination are discussed.
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Affiliation(s)
- P J Lorenzoni
- Neurology Division, Department of Internal Medicine, Federal University of Paraná, Curitiba PR, Brazil
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33
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Tsujii T, Nishikawa N, Tanabe N, Iwaki H, Nagai M, Nomoto M. [Myasthenia gravis complicated with optic neuritis showing anti-aquaporin 4 antibody: a case report]. Rinsho Shinkeigaku 2012; 52:503-6. [PMID: 22849994 DOI: 10.5692/clinicalneurol.52.503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a 33-year-old woman with myasthenia gravis (MG) who developed optic neuritis after the treatment of MG for 22 years. At 10 years of age, she was diagnosed with generalized MG (MGFA V) and at 11 years, she underwent thymectomy. She had been treated successfully only with anti-cholinesterase inhibitors for 22 years despite lasting high titer of anti-acetylcholine receptor antibody. She could manage everything in her life and had two children. At 33 years of age, she experienced acute visual loss in her left eye. Laboratory examination showed positive anti-acetylcholine receptor, antinuclear, anti-ssDNA, anti-dsDNA, anti-SS-A, and anti-aquaporin 4 (AQP4) antibodies. Brain MRI showed an enlarged left optic nerve with enhancement by gadolinium. Three courses of steroid pulse therapy did not show any effect on her visual acuity. However, plasma exchange therapy mildly ameliorated her visual acuity. Her MG symptoms were not exacerbated during the course of the optic neuritis. Furthermore blephalopstosis caused by MG has disappeared completely after the treatment with steroid pulse and plasma exchange. This case had 23 years of immunosuppressive treatment free durations with stable condition. The cause of development of optic neuritis would be her predisposed tendency other than thymectomy or treatment with immunosuppressive therapies.
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Affiliation(s)
- Tomoaki Tsujii
- Department of Neurology and Clinical Pharmacology, Ehime University Hospital
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34
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Maruyama E, Minami N, Niino M, Fujiki N, Doi S, Watanabe M, Shima K, Kikuchi S, Sasaki H. Impact of screening with thyroid ultrasonography in myasthenia gravis patients. Acta Neurol Scand 2012; 125:398-402. [PMID: 21824114 DOI: 10.1111/j.1600-0404.2011.01580.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This study was conducted to screen thyroid abnormality evaluated with ultrasonography (US) in patients with myasthenia gravis (MG) and investigate further when malignancy is suspected. METHODS Thyroid screening using US was conducted in 162 patients with MG. In cases where malignancy was suspected, further investigations were performed. RESULTS Abnormal US findings were detected in 125 of 162 patients with MG (72 patients with nodules, 74 patients with cysts, 27 patients with diffuse findings such as enlargement, atrophy, a hypoechoic pattern or a heterogenous echoic pattern, and 28 patients with calcification). From among these 125 subjects, 30 patients underwent further examinations such as needle aspiration cytology. As a result, six patients (3.7% of 162 cases) were positive for papillary carcinoma. The size of the carcinoma in three patients was <10 mm, yet the stage of thyroid carcinomas was high (stage III or IVa) in all six cases. CONCLUSIONS Our data suggest that the prevalence of thyroid carcinoma in cases of MG may be higher than that of the general population. Furthermore, in patients with MG, there is a possibility that the stage of the carcinoma is higher even when the carcinoma is of a very small size. Patients with MG, when diagnosed, should be advised to undergo US screening of the thyroid because most cases of thyroid carcinoma are highly curable.
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Affiliation(s)
- E Maruyama
- Department of Clinical Laboratory, Hokkaido Medical Center, Sapporo, Japan
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35
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Mizokami T, Itoh Y, Sato Y, Nunoi K, Okamura K. Isolated adrenocorticotropin deficiency associated with painless thyroiditis: a case report and review of the literature. Kurume Med J 2012; 59:71-7. [PMID: 23823017 DOI: 10.2739/kurumemedj.59.71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 53-year-old Japanese man was admitted with a 3-month history of transient headache followed by general fatigue and weight loss. He had a history of ocular myasthenia gravis which had been in remission following thymectomy 30 years ago. He had a small diffuse goiter without tenderness, and was diagnosed as having painless thyroiditis with mild thyrotoxicosis on admission. Endocrinological studies showed he had isolated adrenocorticotropin deficiency. Magnetic resonance imaging of the pituitary gland revealed no abnormalities. His symptoms improved soon after replacement of glucocorticoid. After an episode of hypothyroidism, he spontaneously became euthyroid. It is likely that thyrotoxicosis uncovered adrenal insufficiency that had developed insidiously, and hypoadrenocorticism-induced immunological changes may have triggered the development of painless thyroiditis. Moreover, thymectomy might have facilitated the development of pituitary and thyroid autoimmunity.
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Affiliation(s)
- Tetsuya Mizokami
- Division of Endocrinology and Metabolism, St. Mary's Hospital, Kurume, Japan.
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36
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Wang N, Shen N, Vyse TJ, Anand V, Gunnarson I, Sturfelt G, Rantapää-Dahlqvist S, Elvin K, Truedsson L, Andersson BA, Dahle C, Örtqvist E, Gregersen PK, Behrens TW, Hammarström L. Selective IgA deficiency in autoimmune diseases. Mol Med 2011; 17:1383-96. [PMID: 21826374 PMCID: PMC3321806 DOI: 10.2119/molmed.2011.00195] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 08/02/2011] [Indexed: 12/12/2022] Open
Abstract
Selective immunoglobulin A deficiency (IgAD) is the most common primary immunodeficiency in Caucasians. It has previously been suggested to be associated with a variety of concomitant autoimmune diseases. In this review, we present data on the prevalence of IgAD in patients with Graves disease (GD), systemic lupus erythematosus (SLE), type 1 diabetes (T1D), celiac disease (CD), myasthenia gravis (MG) and rheumatoid arthritis (RA) on the basis of both our own recent large-scale screening results and literature data. Genetic factors are important for the development of both IgAD and various autoimmune disorders, including GD, SLE, T1D, CD, MG and RA, and a strong association with the major histocompatibility complex (MHC) region has been reported. In addition, non-MHC genes, such as interferon-induced helicase 1 (IFIH1) and c-type lectin domain family 16, member A (CLEC16A), are also associated with the development of IgAD and some of the above diseases. This indicates a possible common genetic background. In this review, we present suggestive evidence for a shared genetic predisposition between these disorders.
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Affiliation(s)
- Ning Wang
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Nan Shen
- Department of Rheumatology, Renji Hospital, JiaoTong University School of Medicine, Shanghai, China
| | - Timothy J Vyse
- Section of Molecular Genetics and Rheumatology, Hammersmith Hospital, London, United Kingdom
| | - Vidya Anand
- Section of Molecular Genetics and Rheumatology, Hammersmith Hospital, London, United Kingdom
| | - Iva Gunnarson
- Rheumatology Unit, Department of Medicine, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Gunnar Sturfelt
- Department of Rheumatology, Lund University Hospital, Lund, Sweden
| | | | - Kerstin Elvin
- Unit of Clinical Immunology, Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Lennart Truedsson
- Department of Laboratory Medicine, Section of Microbiology, Immunology and Glycobiology, Lund University, Sweden
| | | | - Charlotte Dahle
- Clinical Immunology Unit, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Eva Örtqvist
- Department of Woman and Child Health, Astrid Lindgren Children’s Hospital, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Peter K Gregersen
- Robert S. Boas Center for Genomics and Human Genetics, Feinstein Institute for Medical Research, Manhasset, New York, United States of America
| | - Timothy W Behrens
- Division of Immunology, Tissue Growth & Repair, Biomarker Discovery and Human Genetics, Genentech, South San Francisco, California, United States of America
| | - Lennart Hammarström
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
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Ramanujam R, Piehl F, Pirskanen R, Gregersen PK, Hammarström L. Concomitant autoimmunity in myasthenia gravis--lack of association with IgA deficiency. J Neuroimmunol 2011; 236:118-22. [PMID: 21669464 DOI: 10.1016/j.jneuroim.2011.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 05/14/2011] [Accepted: 05/14/2011] [Indexed: 12/20/2022]
Abstract
A marked increase in concomitant autoimmune diseases has previously been noted in patients with myasthenia gravis (MG). We show that these diseases occur both before and after the onset of MG and that the process is not influenced by thymectomy. IgA deficiency (IgAD), which is strongly associated with the same HLA haplotype as early onset MG, has recently been suggested to be an autoimmune disease. However, there was no increase in the prevalence of IgAD in a large cohort of Swedish MG patients.
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Affiliation(s)
- Ryan Ramanujam
- Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
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Mao ZF, Yang LX, Mo XA, Qin C, Lai YR, He NY, Li T, Hackett ML. Frequency of autoimmune diseases in myasthenia gravis: a systematic review. Int J Neurosci 2010; 121:121-9. [PMID: 21142828 DOI: 10.3109/00207454.2010.539307] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The course of myasthenia gravis (MG) may get complicated by the development of other autoimmune diseases. Estimates of the frequency of autoimmune diseases will help inform patients and physicians, direct health policy discussion, provide etiologic clues, and optimize the management of MG. However, the frequency of autoimmune diseases in people with MG is still uncertain. A systematic search for English language studies was conducted by MEDLINE and EMBASE from 1960 through 2010. Incidence studies and case series of all MG subtypes with information about autoimmune diseases were included; 25 studies met the inclusion criteria. Although there was considerable heterogeneity, the pooled estimate of the coexisting autoimmune diseases in MG was 13% (95% confidence interval, 12%-14%). Autoimmune thyroid disease seems to occur more frequently than other autoimmune conditions in MG patients. Heterogeneity in study estimates could be explained by ascertainment bias and case mix. Furthermore, autoimmune diseases occurred significantly more often in females and anti-acetylcholine receptor seropositive MG patients. Patients with MG have an increased frequency of coexisting autoimmune diseases. Autoimmune diseases seem to occur more often in female and seropositive MG patients. Further research is needed to expand our understanding of these associations.
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Affiliation(s)
- Zhi-Feng Mao
- Department of Neurology, Third Affiliated Hospital, Guangxi Medical University, Nanning, PR China.
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Finsterer J, Höflich S. Successful low-dose azathioprine for myasthenia gravis despite hepatopathy from primary sclerosing cholangitis: a case report. J Med Case Rep 2010; 4:356. [PMID: 21059205 PMCID: PMC2988809 DOI: 10.1186/1752-1947-4-356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Accepted: 11/08/2010] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Although myasthenia gravis is frequently associated with other disorders, it has not been reported together with primary sclerosing cholangitis, complicating the administration of liver-toxic immunosuppressive therapy. CASE PRESENTATION A 73-year-old Caucasian woman with a history of arterial hypertension, thyroid dysfunction, glaucoma, right-sided ptosis and later generalized weakness, was diagnosed with myasthenia gravis. Additionally, primary sclerosing cholangitis was detected, initially prohibiting the administration of immunosuppressants. Despite treatment with steroids and pyridostigmine she repeatedly experienced myasthenic crises. After the fifth crisis and after antibody titers had reached levels > 100 nmol/L during two years of follow-up, it was decided to restart azathioprine. Interestingly, low-dose azathioprine (1.5 mg/kg/day) was well tolerated, had a positive clinical and immunological effect and did not worsen primary sclerosing cholangitis. CONCLUSION Myasthenia gravis may occur together with primary sclerosing cholangitis in the same patient. Mild immunosuppression with azathioprine is feasible and effective in such a patient, without worsening myasthenia gravis or primary sclerosing cholangitis.
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Affiliation(s)
- Josef Finsterer
- Krankenanstalt Rudolfstiftung, Juchg, 25, 1030, Vienna, Austria.
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Cimaz R, Gana S, Braccesi G, Guerrini R. Sydenham's chorea in a girl with juvenile idiopathic arthritis treated with anti-TNFalpha therapy. Mov Disord 2010; 25:511-4. [PMID: 20014056 DOI: 10.1002/mds.22923] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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