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Keovilayhong S, Mulliez A, Feral L, Chenaf C, Clavelou P, Moisset X, Taithe F, Poncet Megemont L. Epidemiology of myasthenia gravis in France: Incidence, prevalence, and comorbidities based on national healthcare insurance claims data. Rev Neurol (Paris) 2024; 180:451-458. [PMID: 38582663 DOI: 10.1016/j.neurol.2024.02.392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 12/13/2023] [Accepted: 02/09/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The European literature has reported high variability in the incidence and prevalence rates of myasthenia gravis (MG), but no specific epidemiological data for France have been published. This study aimed to assess the incidence and prevalence rates of myasthenia gravis in France based on data extracted from the French National Health Insurance Claims Database (the SNIIRAM database). METHODS We conducted a retrospective repeated cross-sectional population study from 2008 to 2018 using a representative sample of the French population (Échantillon généraliste des bénéficiaires) covered by health insurance. We calculated the incidence, prevalence, and sex ratio of MG and screened for comorbidities associated with MG (standardized to the general population). RESULTS In total, 331 MG patients were identified between 2008 and 2018. The average incidence of MG in France was 50 per million person-years, while the mean prevalence was 465 per million people. The female-to-male ratio was 1.33. The Incidence of MG gradually increased from 40years of age for women and 60 for men. Thymoma was present for 5.1% of MG patients and a thymectomy was performed for 4.7%. Thyroid disease was the most prevalent autoimmune comorbidity, affecting approximately 8.5% of cases. MG patients had an increased cancer risk, with a standardized rate ratio of 2.38 (95% CI: 1.64-3.46). CONCLUSION The incidence and prevalence rates of MG are significantly higher than those previously reported in the literature and the incidence increases with age. The excess risk of cancer raises concerns for MG patients, in particular, concerning the management of immunosuppressive drugs.
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Affiliation(s)
- S Keovilayhong
- Mittaphab Hospital, Vientiane, Lao Democratic People's Republic
| | - A Mulliez
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - L Feral
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - C Chenaf
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - P Clavelou
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France; Neuro-Dol, Inserm, Clermont-Ferrand, France
| | - X Moisset
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France; Neuro-Dol, Inserm, Clermont-Ferrand, France
| | - F Taithe
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - L Poncet Megemont
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France.
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Su M, Luo Q, Wu Z, Feng H, Zhou H. Thymoma-associated autoimmune encephalitis with myasthenia gravis: Case series and literature review. CNS Neurosci Ther 2024; 30:e14568. [PMID: 38421083 PMCID: PMC10850820 DOI: 10.1111/cns.14568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 11/20/2023] [Accepted: 12/02/2023] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVES This comprehensive review aimed to compile cases of patients with thymoma diagnosed with both autoimmune encephalitis (AE) and myasthenia gravis (MG), and describe their clinical characteristics. METHODS Clinical records of 3 AE patients in the first affiliated hospital of Sun Yat-sen University were reviewed. All of them were diagnosed with AE between 1 November 2021 and 1 March 2022, and clinical evidence about thymoma and MG was found. All published case reports were searched for comprehensive literature from January 1990 to June 2022. RESULTS A total of 18 cases diagnosed with thymoma-associated autoimmune encephalitis (TAAE) and thymoma-associated myasthenia gravis (TAMG) were included in this complication, wherein 3 cases were in the first affiliated hospital of Sun Yat-sen University and the other 15 were published case reports. 5/18 patients had alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor antibody (AMPAR-Ab) in their serum and cerebrospinal fluid (CSF). All of them had positive anti-acetylcholine receptor antibody (AChR-Ab). And 12/18 patients showed a positive response to thymectomy and immunotherapy. Besides, thymoma recurrences were detected because of AE onset. And the shortest interval between operation and AE onset was 2 years in patients with thymoma recurrence. CONCLUSIONS There was no significant difference in the clinical manifestations between these patients and others with only TAMG or TAAE. TAAE was commonly associated with AMPAR2-Ab. Significantly, AE more commonly heralded thymoma recurrences than MG onset. And the intervals of thymectomy and MG or AE onset had different meanings for thymoma recurrence and prognoses of patients.
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Affiliation(s)
- Miao Su
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Qiuyan Luo
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
- Department of NeurologyGuangzhou Women and Children's Medical CenterGuangzhouChina
| | - Zichao Wu
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Huiyu Feng
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Hongyan Zhou
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
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Stingu E, Dobrowolski JM, Bombach P, Nann D, Singer S, Horger M, Lauer UM, Zender L, Hinterleitner C, Hinterleitner M. Myasthenia gravis as initial presentation of a pancreatic neuroendocrine tumor: A case report. Exp Ther Med 2023; 26:523. [PMID: 37854502 PMCID: PMC10580239 DOI: 10.3892/etm.2023.12222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/21/2023] [Indexed: 10/20/2023] Open
Abstract
Myasthenia gravis (MG) is a heterogeneous autoimmune disease, which is characterized by a postsynaptic neuromuscular transmission defect, with antibodies directly targeting the acetylcholine receptor (AChR) or other structural proteins of the neuromuscular junction. The majority of MG cases are associated with thymic pathologies, including thymoma, thyroiditis, autoimmune diseases or malignant hematologic neoplasia. The present study reported a rare case of AChR-positive and late-onset ocular MG, which rapidly progressed to a generalized myasthenic syndrome as an initial presentation of a pancreatic neuroendocrine neoplasia (pNEN). Following complete surgical resection of the pNEN, the myasthenic syndrome was improved and the anti-AChR antibody titers were reduced. It has been reported that MG is a paraneoplastic syndrome in thymic neoplasms and less common in hematologic malignancies. However, currently, only few cases of MG as initial presentation of a solid tumor, and more particular of a neuroendocrine neoplasm, have been reported in the literature. In conclusion, surveillance for extrathymic solid malignancies in newly diagnosed patients with MG could promote the early diagnosis of associated tumor diseases.
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Affiliation(s)
- Elena Stingu
- Department of Medical Oncology and Pneumology (Internal Medicine VIII), University Hospital Tuebingen, D-72076 Tuebingen, Germany
- DFG Cluster of Excellence 2180 ‘Image-Guided and Functional Instructed Tumor Therapy’, University of Tuebingen, D-72076 Tuebingen, Germany
| | - Jerome-Maurice Dobrowolski
- Department of Medical Oncology and Pneumology (Internal Medicine VIII), University Hospital Tuebingen, D-72076 Tuebingen, Germany
- DFG Cluster of Excellence 2180 ‘Image-Guided and Functional Instructed Tumor Therapy’, University of Tuebingen, D-72076 Tuebingen, Germany
| | - Paula Bombach
- Department of Neurology and Interdisciplinary Neuro-Oncology, University Hospital Tuebingen, D-72076 Tuebingen, Germany
| | - Dominik Nann
- Department of Pathology, University Hospital Tuebingen, D-72076 Tuebingen, Germany
| | - Stephan Singer
- Department of Pathology, University Hospital Tuebingen, D-72076 Tuebingen, Germany
| | - Marius Horger
- Department of Radiology, University Hospital Tuebingen, D-72076 Tuebingen, Germany
| | - Ulrich M. Lauer
- Department of Medical Oncology and Pneumology (Internal Medicine VIII), University Hospital Tuebingen, D-72076 Tuebingen, Germany
- DFG Cluster of Excellence 2180 ‘Image-Guided and Functional Instructed Tumor Therapy’, University of Tuebingen, D-72076 Tuebingen, Germany
- German Cancer Consortium, German Cancer Research Center, D-72076 Tuebingen, Germany
| | - Lars Zender
- Department of Medical Oncology and Pneumology (Internal Medicine VIII), University Hospital Tuebingen, D-72076 Tuebingen, Germany
- DFG Cluster of Excellence 2180 ‘Image-Guided and Functional Instructed Tumor Therapy’, University of Tuebingen, D-72076 Tuebingen, Germany
- German Cancer Consortium, German Cancer Research Center, D-72076 Tuebingen, Germany
| | - Clemens Hinterleitner
- Department of Medical Oncology and Pneumology (Internal Medicine VIII), University Hospital Tuebingen, D-72076 Tuebingen, Germany
- DFG Cluster of Excellence 2180 ‘Image-Guided and Functional Instructed Tumor Therapy’, University of Tuebingen, D-72076 Tuebingen, Germany
- Cancer Biology and Genetics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Martina Hinterleitner
- Department of Medical Oncology and Pneumology (Internal Medicine VIII), University Hospital Tuebingen, D-72076 Tuebingen, Germany
- DFG Cluster of Excellence 2180 ‘Image-Guided and Functional Instructed Tumor Therapy’, University of Tuebingen, D-72076 Tuebingen, Germany
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4
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Gosain D, Das T. Myasthenia Gravis Presenting as Bulbar Palsy. Cureus 2023; 15:e46082. [PMID: 37900462 PMCID: PMC10611170 DOI: 10.7759/cureus.46082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/31/2023] Open
Abstract
Myasthenia gravis is a rare autoimmune condition that affects postsynaptic cholinergic receptors, resulting in symptoms of muscular fatigue. Clinical signs could be subtle and variable, often leading to many differentials. This leads to inappropriate tests being performed and a delay in diagnosis. Although ocular signs are more common, it may rarely present as bulbar palsy. Our patient, in her 30s, was referred to the emergency department after six months of symptom onset when she was discovered to be at a high risk of silent aspiration. Her presentation was predominantly bulbar palsy, but after appropriate tests, she was eventually diagnosed with generalized myasthenia gravis with a concurrent thymoma. Her treatment included pyridostigmine, corticosteroid, and immunoglobulins, while a thymectomy was scheduled as a planned procedure. Prompt diagnosis and timely management can reduce morbidity and mortality in such cases.
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Affiliation(s)
- Dhruv Gosain
- General Internal Medicine, Peterborough City Hospital, Peterborough, GBR
| | - Tapas Das
- Gastroenterology, Peterborough City Hospital, Peterborough, GBR
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5
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Lococo F, Nachira D, Chiappetta M, Evangelista J, Falcoz PE, Ruffini E, Van Schil P, Scarci M, Furàk J, Sollitto F, Guerrera F, Spaggiari L, Aigner C, Evangelia L, Billè A, Moser B, Thomas PA, Liberman M, Boubia S, Campisi A, Ampollini L, Toker A, Enyed A, Voltolini L, Van Raemdonck D, Margaritora S. Does Myasthenia Gravis Affect Long-Term Survival in Thymic Carcinomas? An ESTS Database Analysis. Diagnostics (Basel) 2022; 12:diagnostics12071764. [PMID: 35885668 PMCID: PMC9319380 DOI: 10.3390/diagnostics12071764] [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: 06/08/2022] [Revised: 07/04/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Thymic carcinoma is a rare and highly malignant tumor with a dismal prognosis, which occasionally coexists with myasthenia gravis (MG). This study aims to investigate the MG incidence on a surgical cohort of patients with thymic carcinoma and to explore its influence on long-term survival. Methods: the prospectively collected data from the ESTS database on thymic epithelial tumors were reviewed. Clinical, pathological, and survival information on thymic carcinoma were analyzed. Results: the analysis was conducted on 203 patients, with an equal gender distribution (96 males and 107 females). MG was detected in 22 (10.8%) patients, more frequently elderly (>60 years, p = 0.048) and male (p = 0.003). Induction therapy was performed in 22 (10.8%) cases. After surgery, 120 (59.1%) patients had a Masaoka stage II−III while complete resection (R0) was achieved in 158 (77.8%). Adjuvant therapy was performed in 68 cases. Mean follow-up was 60 (SD = 14) months. The 3-year, 5-year and 10-year survival rates were 79%, 75% and 63%, respectively. MG did not seem to influence long-term survival (5-year survival in non-MG−TCs 78% vs. 50% in MG−TCs, p = ns) as age < 60 years, female gender, early Masaoka stage, and postoperative radiotherapy did, conversely. Conclusions: myasthenia occurred in about 10% of thymic carcinomas and it did not seem to affect significantly the long-term prognosis in surgically treated thymic carcinoma-patients.
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Affiliation(s)
- Filippo Lococo
- Thoracic Surgey, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.L.); (D.N.); (J.E.); (S.M.)
- Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Dania Nachira
- Thoracic Surgey, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.L.); (D.N.); (J.E.); (S.M.)
- Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Marco Chiappetta
- Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Correspondence: or largoa.gemellie-
| | - Jessica Evangelista
- Thoracic Surgey, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.L.); (D.N.); (J.E.); (S.M.)
- Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Pierre Emmanuel Falcoz
- Department of Surgical Sciences, Strasbourg University Hospital, 67000 Strasbourg, France;
| | - Enrico Ruffini
- Department of Surgical Sciences, University of Torino, 10124 Torino, Italy; (E.R.); (F.G.)
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Antwerp University, 2000 Antwerp, Belgium;
| | - Marco Scarci
- Thoracic Surgery Divison of Cardiothoracic Surgery, Imperial College NHS Healthcare Trust, Du Cane Road, London W12 0HS, UK;
| | - Jòzsef Furàk
- Department of Surgery, University of Szeged, Semmelweis u. 8, H-6725 Szeged, Hungary;
| | | | - Francesco Guerrera
- Department of Surgical Sciences, University of Torino, 10124 Torino, Italy; (E.R.); (F.G.)
| | - Lorenzo Spaggiari
- Division of Thoracic Surgery, IEO, European Institute of Oncology, IRCCS, 20139 Milan, Italy;
| | - Clemens Aigner
- Department of Thoracic Surgery, Essen University Hospital—Ruhrlandklinik, 45239 Essen, Germany;
| | | | - Andrea Billè
- Thoracic Surgery Department, Guys Hospital London, London SE1 9RT, UK;
| | - Bernhard Moser
- Department of Thoracic Surgery, Medical University of Vienna, 1090 Vienna, Austria;
| | - Pascal Alexandre Thomas
- Department of Thoracic Surgery, North Hospital Aix-Marseille University, 13015 Marseille, France;
| | - Moishe Liberman
- Division of Thoracic Surgery—Centre Hospital de l’Universite de Montreal, University of Montreal, 900 Rue Saint-Denis, Montreal, QC H2X 0A9, Canada;
| | - Souheil Boubia
- Department of Thoracic Surgery, Universitary Hospital Ibn Rochd Casablanca, Casablanca 20250, Morocco;
| | - Alessio Campisi
- Cardiovascular and Thoracic Department, University of Verona School of Medicine and Verona University Hospital Trust, 37126 Verona, Italy;
| | - Luca Ampollini
- Unit of Thoracic Surgery, Azienda Ospedaliera-Universitaria di Parma, 43126 Parma, Italy;
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV 26506, USA;
| | - Attila Enyed
- Department of Surgery, Faculty of Medicine, University of Debrecen, 22 Moricz Zsigmond Str., H-4032 Debrecen, Hungary;
| | - Luca Voltolini
- Thoracic Surgery Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Stefano Margaritora
- Thoracic Surgey, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (F.L.); (D.N.); (J.E.); (S.M.)
- Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
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Treatment and Management of Disorders of the Neuromuscular Junction. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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7
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Holroyd KB, Rubin DB, Vaitkevicius H. Neurologic Complications in Patients with Cancer. Semin Neurol 2021; 41:588-605. [PMID: 34619783 DOI: 10.1055/s-0041-1733788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurologic symptoms are commonly seen in patients with cancer and can be among the most challenging to diagnose and manage. It is often difficult to determine if new neurologic symptoms are secondary to direct effects of a malignant lesion, systemic complications of disease, paraneoplastic disorders, or side effects of cancer treatment itself. However, early diagnosis and treatment of each of these conditions can improve patients' quality of life and long-term functional outcomes. In this review, we describe a systematic approach to the diagnosis of new neurologic symptoms in patients with known malignancy. We have categorized the neurologic complications of cancer through a mechanistic approach, with an emphasis on ascertaining underlying pathophysiology to guide treatment choice. This review focuses on the acute neurologic complications of cancer that require hospital admission.
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Affiliation(s)
| | - Daniel B Rubin
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, Massachusetts
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8
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Uğur T, Gürler F, Cengiz B, Kuruoğlu R, Özet A. A Case of Myasthenia Gravis with Two Primary Tumors: Paraneoplastic or Incidental? J Gastrointest Cancer 2021; 53:837-840. [PMID: 34463912 DOI: 10.1007/s12029-021-00702-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Tuba Uğur
- Department of Internal Medicine, Gazi University, Ankara, Turkey
| | - Fatih Gürler
- Department of Medical Oncology, Gazi University, Besevler/Ankara, Turkey.
| | - Bülent Cengiz
- Department of Neurology, Gazi University, Ankara, Turkey
| | - Reha Kuruoğlu
- Department of Neurology, Gazi University, Ankara, Turkey
| | - Ahmet Özet
- Department of Medical Oncology, Gazi University, Besevler/Ankara, Turkey
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9
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Yao Y, Li X, Lin J, Zhang X, Wang H. Thymoma-associated autoimmune encephalitis with positive Titin antibodies: A case report. J Neuroimmunol 2021; 358:577670. [PMID: 34325343 DOI: 10.1016/j.jneuroim.2021.577670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/19/2021] [Accepted: 07/19/2021] [Indexed: 11/16/2022]
Abstract
We report a case of thymoma-associated autoimmune encephalitis with positive Titin antibodies. The patient had cognitive dysfunction, psychiatric symptoms and symptomatic epilepsy. PET-CT indicated space-occupied lesion at the thoracic entrance. The patient was diagnosed with paraneoplastic autoimmune encephalitis. After immunotherapy, his condition improved and underwent thymectomy. Pathology revealed type A thymoma. The patient recurred 10 days after the operation. Thymoma is associated with AE. And Titin antibodies may be involved in the extensive immune response to antigens which the patient's thymoma ectopically expressed. This case reflects the complexity of the immune relationship among autoimmune encephalitis, Titin antibodises and thymoma. Titin antibody may have a certain guiding significance for the treatment and prognosis of autoimmune encephalitis.
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Affiliation(s)
- Yu Yao
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Xiang Li
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Jie Lin
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Xu Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
| | - Hanmin Wang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
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Zheng Y, Luo J, Jin H, Liu R, Hao H, Gao F. Myasthenia gravis associated with renal cell carcinoma: a paraneoplastic syndrome or just a coincidence. BMC Neurol 2021; 21:277. [PMID: 34253185 PMCID: PMC8273985 DOI: 10.1186/s12883-021-02311-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 07/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myasthenia gravis (MG) can occur as a paraneoplastic phenomenon associated with thymoma. The association of MG with renal cell carcinoma (RCC) is not clear. Herein, we describe six cases of MG associated with RCC. METHODS There were 283 patients diagnosed with MG admitted to our hospital from 2014 to 2019. Among them, 6 patients also had RCC. None of them had immune checkpoint inhibitor therapies. We performed a retrospective clinical data collection and follow-up studies of these 6 patients. RESULTS These 6 patients with an average MG onset age of 61.3 ± 13.3 years, were all positive for anti-acetylcholine receptor antibodies. MG symptoms appeared after RCC resection in 3 cases. RCC was discovered after the onset of MG in 2 cases, and synchronously with MG in 1 case. After nephrectomy, the MG symptoms showed a stable complete remission in 1 case. Among them, four patients met the diagnostic criteria of possible paraneoplastic neurological syndromes. CONCLUSIONS Except for thymoma, patients with MG should pay attention to other tumors including RCC. MG may be a paraneoplastic syndrome of RCC, and further studies are needed to elucidate the relationship.
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Affiliation(s)
- Yiming Zheng
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Beijing, 100034, China
| | - Jingjing Luo
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Beijing, 100034, China
| | - Haiqiang Jin
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Beijing, 100034, China
| | - Ran Liu
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Beijing, 100034, China
| | - Hongjun Hao
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Beijing, 100034, China.
| | - Feng Gao
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Beijing, 100034, China.
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Comorbidities worsen the prognosis of generalized myasthenia gravis post-thymectomy. J Neurol Sci 2021; 427:117549. [PMID: 34167051 DOI: 10.1016/j.jns.2021.117549] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The effect of comorbidities on the prognosis of myasthenia gravis (MG) remains unclear. In particular, the role of other autoimmune diseases (AD) is controversial. METHODS In this retrospective single-center cohort study, we investigated 154 consecutive generalized thymectomized MG patients, with a mean follow-up time of 8.6 (±5.0) years post-thymectomy. Comorbidities diagnosed at any timepoint were retrieved from medical records and Charlson comorbidity index (CCI) scores were calculated. Patients were categorized into subgroups MG alone (n = 45) and MG with any comorbidity (n = 109); the latter was further categorized into MG with other ADs (n = 33) and MG with non-AD comorbidities (n = 76). The endpoints analyzed were complete stable remission (CSR), minimal need for medications, and need for in-hospital treatments. RESULTS CSR was more frequent in MG alone than in MG with any comorbidity group (26.7% vs 8.3%, p = 0.004). Minimal need for medication was reached more often in the MG alone than in the MG with non-AD comorbidities group (p = 0.047). Need for in-hospital treatments was lower in the MG alone group than in MG patients with any comorbidity (p = 0.046). Logistic regression analysis revealed that lower CCI scores increased the likelihood of CSR (p = 0.033). Lower CCI scores were more prevalent both in patients with minimal need for medication and in patients who did not need in-hospital treatments (p < 0.001). CONCLUSIONS Patients with generalized MG and comorbidities have a poorer prognosis than patients with MG alone during almost 9 years follow-up after thymectomy. AD comorbidities appeared not to translate into a higher risk compared to other comorbidities.
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12
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Hayashi N, Sone J, Fukami Y, Yoshida Y, Kuno S, Shimada K, Atsuta N, Nakamura T, Higuchi O, Katsuno M. Severe myasthenia gravis with anti-LRP4 antibodies and Hodgkin lymphoma. Muscle Nerve 2020; 63:E2-E4. [PMID: 32996610 DOI: 10.1002/mus.27079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Naoki Hayashi
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jun Sone
- Department of Neurology, National Hospital Organization Suzuka National Hospital, Suzuka, Japan
| | - Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Yoshida
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shunsuke Kuno
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuyuki Shimada
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Atsuta
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomohiko Nakamura
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Osamu Higuchi
- Department of Clinical Research, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Lefeuvre CMJ, Payet CA, Fayet OM, Maillard S, Truffault F, Bondet V, Duffy D, de Montpreville V, Ghigna MR, Fadel E, Mansuet-Lupo A, Alifano M, Validire P, Gossot D, Behin A, Eymard B, Berrih-Aknin S, Le Panse R. Risk factors associated with myasthenia gravis in thymoma patients: The potential role of thymic germinal centers. J Autoimmun 2020; 106:102337. [DOI: 10.1016/j.jaut.2019.102337] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 12/17/2022]
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O'Connell E, Harper A, Blundell R, Batchelor D. Paraneoplastic immune-mediated neutropenia in a dog following thymoma excision with later development of metastatic thymic carcinoma treated with toceranib phosphate. VETERINARY RECORD CASE REPORTS 2018. [DOI: 10.1136/vetreccr-2017-000548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A thymoma was an incidental finding in a seven-year-old, female neutered, crossbred dog referred for an acute hepatopathy. Excision of the thymoma was performed via median sternotomy, and 11 weeks later the dog presented with severe neutropenia. The bone marrow was hypercellular, and paraneoplastic immune-mediated neutropenia was diagnosed following exclusion of other causes. The neutrophil count increased to normal within seven days of treatment with prednisolone, which was subsequently tapered. A caudal mediastinal mass was documented 17 months following initial thymoma excision, and pleural and mediastinal metastases were evident on CT. Cytology was consistent with carcinoma. Following the prescription of toceranib phosphate, there was stable disease on CT at eight weeks and six months. At 12 months there was severe locoregional progression and the dog died nine days thereafter. Postmortem examination showed diffuse metastatic carcinoma of the caudal mediastinum, parietal pleura and diaphragm, and histopathology/immunohistochemistry was most consistent with thymic carcinoma.
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Fratalia L, Larner AJ. Late onset myasthenia gravis and carcinoid tumour: paraneoplastic syndrome? Br J Hosp Med (Lond) 2017; 78:588-589. [PMID: 29019733 DOI: 10.12968/hmed.2017.78.10.588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- L Fratalia
- Consultant Neurologist, Walton Centre for Neurology and Neurosurgery, Liverpool
| | - A J Larner
- Consultant Neurologist, Walton Centre for Neurology and Neurosurgery, Liverpool L9 7LJ
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Ruelle L, Bentea G, Sideris S, El Koulali M, Holbrechts S, Lafitte JJ, Grigoriu B, Sculier C, Meert AP, Durieux V, Berghmans T, Sculier JP. Autoimmune paraneoplastic syndromes associated to lung cancer: A systematic review of the literature Part 4: Neurological paraneoplastic syndromes, involving the peripheral nervous system and the neuromuscular junction and muscles. Lung Cancer 2017; 111:150-163. [PMID: 28838388 DOI: 10.1016/j.lungcan.2017.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The development of new immune treatment in oncology and particularly for lung cancer may induce new complications, particularly activation or reactivation of auto-immune diseases. In this context, a systematic review on the auto-immune paraneoplastic syndromes that can complicate lung cancer appears useful. This article is the fourth of a series of five and deals mainly with neurological paraneoplastic syndromes involving the peripheral nervous system and the neuromuscular junction and muscles.
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Affiliation(s)
- Lucien Ruelle
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | - Georgiana Bentea
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | - Spyridon Sideris
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | - Mohamed El Koulali
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | | | | | - Bogdan Grigoriu
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | - Claudine Sculier
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium
| | - Anne-Pascale Meert
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium; Laboratoire facultaire de Médecine factuelle (ULB), Belgium
| | - Valérie Durieux
- Laboratoire facultaire de Médecine factuelle (ULB), Belgium; Bibliothèque des Sciences de la Santé, Université libre de Bruxelles (ULB), Belgium
| | - Thierry Berghmans
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium; Laboratoire facultaire de Médecine factuelle (ULB), Belgium
| | - Jean-Paul Sculier
- Service des Soins Intensifs et Urgences Oncologiques & Thoracic Oncology Institut Jules Bordet, Centre des Tumeurs de l'Université Libre de Bruxelles (ULB), Belgium; Laboratoire facultaire de Médecine factuelle (ULB), Belgium.
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Weis CA, Märkl B, Schuster T, Vollert K, Ströbel P, Marx A. [True thymic hyperplasia : Differential diagnosis of thymic mass lesions in neonates and children]. DER PATHOLOGE 2017; 38:286-293. [PMID: 28429039 DOI: 10.1007/s00292-017-0283-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Reactive and neoplastic thymic pathologies are the main considerations in the case of masses in the anterior and middle part of the mediastinum, while neurogenic tumors are predominant in the posterior mediastinum (which are not dealt with here). In neonates and infants, the commonest pathologies in the anterior mediastinum comprise germ cell tumors (mainly teratomas), congenital thymic cysts and true thymic hyperplasia (TTH). In toddlers, teratomas, yolk sac tumors and cysts predominate. In children over 5 years of age, lymphomas are the commonest mass lesions whereas thymomas and thymic carcinomas are rare. In addition, inflammation-linked hyperplasia in myasthenia gravis and rebound thymic hyperplasia after chemotherapy must be considered. Although rare at all ages, sarcomas must be considered in the differential diagnosis from birth onwards and throughout adolescence. Based on the report of a rare case of recurrent TTH, the differential diagnosis of this benign but potentially life-threatening condition is discussed.
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Affiliation(s)
- C-A Weis
- Pathologisches Institut, Universitätsmedizin Mannheim, Universität Heidelberg, Theodor Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - B Märkl
- Institut für Pathologie, Klinikum Augsburg, Augsburg, Deutschland
| | - T Schuster
- Kinderchirurgische Klinik, Klinikum Augsburg, Augsburg, Deutschland
| | - K Vollert
- Klinik für Diagnostische Radiologie und Neuroradiologie, Klinikum Augsburg, Augsburg, Deutschland
| | - P Ströbel
- Institut für Pathologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - A Marx
- Pathologisches Institut, Universitätsmedizin Mannheim, Universität Heidelberg, Theodor Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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Li HF, Hong Y, Xie Y, Hao HJ, Sun RC. Precision medicine in myasthenia graves: begin from the data precision. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:106. [PMID: 27127759 DOI: 10.21037/atm.2016.02.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Myasthenia gravis (MG) is a prototypic autoimmune disease with overt clinical and immunological heterogeneity. The data of MG is far from individually precise now, partially due to the rarity and heterogeneity of this disease. In this review, we provide the basic insights of MG data precision, including onset age, presenting symptoms, generalization, thymus status, pathogenic autoantibodies, muscle involvement, severity and response to treatment based on references and our previous studies. Subgroups and quantitative traits of MG are discussed in the sense of data precision. The role of disease registries and scientific bases of precise analysis are also discussed to ensure better collection and analysis of MG data.
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Affiliation(s)
- Hai-Feng Li
- 1 Department of Neurology, Qilu Hospital of Shandong University, Jinan 250012, China ; 2 Department of Clinical Medicine, University of Bergen, Bergen, Norway ; 3 Department of Neurology, The George Washington University, Washington, DC, USA ; 4 Department of Neurology, Peking University First Hospital, Beijing 100034, China ; 5 College of Information and Engineering, Qingdao University, Qingdao 266071, China
| | - Yu Hong
- 1 Department of Neurology, Qilu Hospital of Shandong University, Jinan 250012, China ; 2 Department of Clinical Medicine, University of Bergen, Bergen, Norway ; 3 Department of Neurology, The George Washington University, Washington, DC, USA ; 4 Department of Neurology, Peking University First Hospital, Beijing 100034, China ; 5 College of Information and Engineering, Qingdao University, Qingdao 266071, China
| | - Yanchen Xie
- 1 Department of Neurology, Qilu Hospital of Shandong University, Jinan 250012, China ; 2 Department of Clinical Medicine, University of Bergen, Bergen, Norway ; 3 Department of Neurology, The George Washington University, Washington, DC, USA ; 4 Department of Neurology, Peking University First Hospital, Beijing 100034, China ; 5 College of Information and Engineering, Qingdao University, Qingdao 266071, China
| | - Hong-Jun Hao
- 1 Department of Neurology, Qilu Hospital of Shandong University, Jinan 250012, China ; 2 Department of Clinical Medicine, University of Bergen, Bergen, Norway ; 3 Department of Neurology, The George Washington University, Washington, DC, USA ; 4 Department of Neurology, Peking University First Hospital, Beijing 100034, China ; 5 College of Information and Engineering, Qingdao University, Qingdao 266071, China
| | - Ren-Cheng Sun
- 1 Department of Neurology, Qilu Hospital of Shandong University, Jinan 250012, China ; 2 Department of Clinical Medicine, University of Bergen, Bergen, Norway ; 3 Department of Neurology, The George Washington University, Washington, DC, USA ; 4 Department of Neurology, Peking University First Hospital, Beijing 100034, China ; 5 College of Information and Engineering, Qingdao University, Qingdao 266071, China
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Association study between IL-17A and IL-17F gene polymorphism and myasthenia gravis in Chinese patients. Neurol Sci 2015; 37:123-130. [PMID: 26337284 DOI: 10.1007/s10072-015-2375-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 08/23/2015] [Indexed: 02/07/2023]
Abstract
Alleles of IL-17A and IL-17F genes were reported to be associated with many inflammatory and autoimmune disorders in Asian patients. Serum level and mRNA of IL-17A in peripheral blood mononuclear cells were reported to be significantly higher in MG patients than in healthy controls. In experimental autoimmune myasthenia gravis (EAMG) animals, IL-17 may have effects on the severity of MG. This study investigated the association between four SNPs of IL-17A and IL-17F gene (rs8193036, rs2275913 and rs3748067 in IL-17A; rs763780 in IL-17F) and MG in Chinese patients. The allele frequencies were compared between 480 MG patients and 487 healthy controls, between each MG subgroup and the control group, and between each pairs of MG subgroups. Subgroups were specified by clinical features (onset age, gender, thymoma, AChRAb and muscle involvement at onset) and maximal severity during the follow-up. No associations were found between the four SNPs of IL-17A and IL-17F gene and MG in Chinese patients.
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Li W, Miao Z, Liu X, Zhang Q, Sun L, Li P, Liu W, Zhang L. Thymic carcinoma patients with myasthenia gravis exhibit better prognoses. Int J Clin Oncol 2015; 21:75-80. [PMID: 26138264 DOI: 10.1007/s10147-015-0862-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 06/10/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Thymic carcinoma is an aggressive mediastinal neoplasm with a poor prognosis, but the factors that contribute to its prognosis are not completely understood. Myasthenia gravis (MG) can coexist with thymic carcinoma with low incidence, but the effect MG has on thymic carcinoma prognosis is unknown. Here, we investigated the prognostic factors of thymic carcinoma and the influence of MG on patients with this disease. METHODS Between January 1996 and December 2012, 49 patients were diagnosed with thymic carcinoma and surgically treated at our institution. Clinical data and survival information were recorded and systematically reviewed. Kaplan-Meier survival curves were generated, and independent prognostic factors were identified by Cox's proportional hazard model. RESULTS Complete resection was achieved in 30 patients (61.2 %), and incomplete resection was performed on the other 19 patients (38.8 %). Six of the 49 patients with thymic carcinoma also presented with MG (12.2 %). Interestingly, these 6 patients exhibited much better prognoses when compared to the other 43 patients. Patients with MG also had significantly smaller tumors (P = 0.045), earlier Masaoka stage (P = 0.048), and higher complete resection rates (P = 0.042). However, multivariate analysis demonstrated that complete resection was the only independent predictor for overall survival (OS) (P < 0.001). CONCLUSIONS The OS of patients with thymic carcinoma depends on complete resection, but patients with MG also demonstrate improved prognoses. MG patients have higher rates of complete surgical resection, which may account for their better prognoses. Patients with MG have unique features that may aid in the clinical management of these patients.
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Affiliation(s)
- Wenya Li
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, No. 155 North Nanjing Street, Shenyang, 110001, Liaoning Province, China
| | - Zhifeng Miao
- Department of Surgical Oncology and General Surgery, The First Affiliated Hospital of China Medical University, Shenyang, 110001, Liaoning Province, China
| | - Xudong Liu
- Department of Rheumatology and Immunology, The First Affiliated Hospital of China Medical University, Shenyang, 110001, Liaoning Province, China
| | - Qigang Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, No. 155 North Nanjing Street, Shenyang, 110001, Liaoning Province, China
| | - Lei Sun
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, No. 155 North Nanjing Street, Shenyang, 110001, Liaoning Province, China
| | - Peiwen Li
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, No. 155 North Nanjing Street, Shenyang, 110001, Liaoning Province, China
| | - Wenke Liu
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, No. 155 North Nanjing Street, Shenyang, 110001, Liaoning Province, China
| | - Lin Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of China Medical University, No. 155 North Nanjing Street, Shenyang, 110001, Liaoning Province, China.
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Ha JC, Richman DP. Myasthenia gravis and related disorders: Pathology and molecular pathogenesis. Biochim Biophys Acta Mol Basis Dis 2015; 1852:651-7. [DOI: 10.1016/j.bbadis.2014.11.022] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 11/20/2014] [Accepted: 11/29/2014] [Indexed: 12/21/2022]
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Hermans MAW, Stelten BML, Haak HR, de Herder WW, Dercksen MW. Two patients with a neuroendocrine tumour of the small intestine and paraneoplastic myasthenia gravis. Endocrinol Diabetes Metab Case Rep 2014; 2014:140013. [PMID: 24839548 PMCID: PMC4023180 DOI: 10.1530/edm-14-0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 04/25/2014] [Indexed: 11/20/2022] Open
Abstract
This paper reports on two patients with a long-standing diagnosis of an ENETS stage IV neuroendocrine tumour (NET) of the small intestine who developed neurological symptoms. The first patient only had bulbar symptoms and tested positive for acetylcholine receptor antibodies. The second patient had more classical symptoms of fatigable diplopia and muscle weakness of the legs, but no detectable antibodies. The diagnosis of paraneoplastical myasthenia gravis (MG) was postulated. Both patients were treated with pyridostigmine for MG and octreotide for the NETs. Interestingly, treatment of the NETs resulted in improvement of myasthenic symptoms. Paraneoplastic MG has been described to occur with certain malignancies, mainly thymoma. Herein, we prove that the association with gastrointestinal NETs, however, rare, is also one to be considered by clinicians dealing with either of these diseases. The pathogenesis has yet to be elucidated.
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Affiliation(s)
- M A W Hermans
- Department of Internal Medicine Maxima Medical Centre Ds Theodor Fliednerstr 1; 5631BM; Eindhoven The Netherlands
| | - B M L Stelten
- Department of Neurology Canisius Wilhelmina Hospital Weg door Jonkerbos 100, 6532SZ, Nijmegen The Netherlands
| | - H R Haak
- Department of Internal Medicine Maxima Medical Centre Ds Theodor Fliednerstr 1; 5631BM; Eindhoven The Netherlands
| | - W W de Herder
- Department of Internal Medicine Erasmus University Medical Centre Gravendijkwal 230, 3015CE, Rotterdam The Netherlands
| | - M W Dercksen
- Department of Internal Medicine Maxima Medical Centre Ds Theodor Fliednerstr 1; 5631BM; Eindhoven The Netherlands
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Ariatti A, Stefani M, Miceli P, Benuzzi F, Galassi G. Prognostic factors and health-related quality of life in ocular Myasthenia Gravis (OMG). Int J Neurosci 2013; 124:427-35. [PMID: 24228829 DOI: 10.3109/00207454.2013.853664] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We evaluate the factors predictive of prognosis in 91 Caucasian patients affected by ocular myasthenia gravis (OMG), followed at our Institution during an observational time, ranging from 12 to 240 months. The Myasthenia Gravis Foundation of America (MGFA) clinical classification was used to grade the disease severity. We considered as outcome measures the variation in two subscores, ocular (O-QMG) and nonocular (NO-QMG); the last one reflected bulbar, neck, extremity functions. None of the independent variables evaluated for association with the outcome, as age of onset, type of therapy, length of interval between first and last examinations, and presence of antibodies to acetylcholine receptors (AChR-Abs) significantly affected the evolution of O-QMG and of NO-QMG. Health-related quality of life (HRQol) was assessed in 63 patients. Variations of diplopia or ptosis did not affect significantly physical (PCS) or mental composite subscores (MCS) of the Short-Form Health Survey (SF-36). Human leukocyte antigen (HLA) genotyping was studied to explore whether HLA class I and II allelic distribution differed among MG patients and controls. None of the studied HLA alleles significantly differed between OMG patients and controls. Similarly, none of the alleles with frequencies higher than 15% either in OMG patients or in controls was significantly associated, after Bonferroni correction, with the presence or absence of anti-AChR-Abs in serum.
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Affiliation(s)
- Alessandra Ariatti
- Department of Neurosciences, and Department of Onco-Haematology, University Hospitals of Modena & Reggio Emilia , Italy
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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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Surgery of myasthenia gravis associated or not with thymoma: a retrospective study of 43 cases. Heart Lung Circ 2013; 22:738-41. [PMID: 23548337 DOI: 10.1016/j.hlc.2013.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 02/08/2013] [Accepted: 02/28/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Thymectomy is a surgical treatment of myasthenia gravis. Our goal is to report our experience in the surgical treatment of myasthenia gravis with or without thymoma and a review of the literature. MATERIALS AND METHODS This is a retrospective study over a period of 10 years (2001-2010) on 43 patients: 28 women and 15 men with a mean age of 39.3 years (range 16-68 years). The myasthenia gravis was confirmed by clinical, electromyographic data and the presence of antibodies to acetylcholine receptors. RESULTS Computed tomography objectified thymic mass in 14 cases (32.5%) enlarged thymus without visible mass in eight cases (18.6%). All patients received anticholinesterase, cortico steroids in 25 cases and in three cases plasmapheresis was required. The surgical approach was total sternotomy (n=32 cases), cervicotomy (n=2), cervical and manubriotomy (n=1), a manubriotomy (n=3) and a thoracotomy in five cases (lateralised thymoma). All patients underwent a total thymectomy associated or not with resection of the tumour. Intensive Care Unit was necessary for at least 24h up to six days. The postoperative course was marked by a myasthaenic crisis (n=2) and respiratory failure (n=3) with a favourable outcome. The prognosis was marked by a complete remission in 14 cases, partial remission in 11 patients, stabilisation (n=16 cases) and increasing crisis in two patients. CONCLUSION Thymectomy certainly allows clinical improvement and reduced crisis of myasthenia gravis. Long term monitoring will confirm the benefit of non-oncological thymectomy alone or in combination with standard treatments for patients with generalised myasthenia gravis without thymoma.
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Pedersen EG, Pottegård A, Hallas J, Friis S, Hansen K, Jensen PEH, Gaist D. Use of azathioprine for non-thymoma myasthenia and risk of cancer: a nationwide case-control study in Denmark. Eur J Neurol 2013; 20:942-8. [DOI: 10.1111/ene.12108] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 12/19/2012] [Indexed: 01/10/2023]
Affiliation(s)
- E. G. Pedersen
- Department of Neurology; Faculty of Health Sciences; Institute of Clinical Research; Odense University Hospital; University of Southern Denmark (SDU); Odense; Denmark
| | - A. Pottegård
- Clinical Pharmacology Unit; Institute of Public Health; SDU; Odense; Denmark
| | - J. Hallas
- Clinical Pharmacology Unit; Institute of Public Health; SDU; Odense; Denmark
| | - S. Friis
- Danish Cancer Society Research Centre; Department of Public Health; University of Copenhagen; Copenhagen; Denmark
| | - K. Hansen
- Department of Neurology; Rigshospitalet; Copenhagen University Hospital; Copenhagen; Denmark
| | - P. E. H. Jensen
- Neuroimmunology Laboratory; Department of Neurology; Rigshospitalet; Copenhagen University Hospital; DMSC; Copenhagen; Denmark
| | - D. Gaist
- Department of Neurology; Faculty of Health Sciences; Institute of Clinical Research; Odense University Hospital; University of Southern Denmark (SDU); Odense; Denmark
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28
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Meriggioli MN, Sanders DB. Muscle autoantibodies in myasthenia gravis: beyond diagnosis? Expert Rev Clin Immunol 2012; 8:427-38. [PMID: 22882218 DOI: 10.1586/eci.12.34] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Myasthenia gravis is an autoimmune disorder of the neuromuscular junction. A number of molecules, including ion channels and other proteins at the neuromuscular junction, may be targeted by autoantibodies leading to abnormal neuromuscular transmission. In approximately 85% of patients, autoantibodies, directed against the postsynaptic nicotinic acetylcholine receptor can be detected in the serum and confirm the diagnosis, but in general, do not precisely predict the degree of weakness or response to therapy. Antibodies to the muscle-specific tyrosine kinase are detected in approximately 50% of generalized myasthenia gravis patients who are seronegative for anti-acetylcholine receptor antibodies, and levels of anti-muscle-specific tyrosine kinase antibodies do appear to correlate with disease severity and treatment response. Antibodies to other muscle antigens may be found in the subsets of myasthenia gravis patients, potentially providing clinically useful diagnostic information, but their utility as relevant biomarkers (measures of disease state or response to treatment) is currently unclear.
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Affiliation(s)
- Matthew N Meriggioli
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois Hospital and Health Sciences System, Chicago, IL 60612, USA.
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29
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Wang Z, Wang W, Chen Y, Wei D. T helper type 17 cells expand in patients with myasthenia-associated thymoma. Scand J Immunol 2012; 76:54-61. [PMID: 22486891 DOI: 10.1111/j.1365-3083.2012.02703.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Myasthenia gravis (MG) is a prototypical CD4(+) T cell-dependent autoimmune disease mediated by anti-acetylcholine receptor autoantibodies (AChR-Abs). Certain subsets of helper T cells are suggested to be involved in the pathogenesis of MG, including Th1 and regulatory T cells (Treg). However, whether the recently identified Th17 cells play a role in the development of MG and its prognosis is still unknown. Here, we demonstrated that Th17 cells and their associated cytokines are increased, while the Treg cells are decreased in the peripheral blood mononuclear cells (PBMCs) from MG patients with thymomas (TM), but not from those with normal thymus (NT) or thymic hyperplasia (TH). Furthermore, the quantity of Th17 cells correlates with the quantitative myasthenia gravis (QMG) score in patients with TM. We also found a significant positive relationship between the frequency of Th17 cells (%) and the concentration of AChR antibodies in patients with MG. Therefore, the Th17/Treg imbalance in TM may suggest MG with certain pathological subtype, and the increase in Th17 cells may reveal the severity of the disease, which is valuable in the diagnosis and choice of therapeutic strategy for patients with MG.
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Affiliation(s)
- Z Wang
- Department of Neurology, 309 Hospital, Beijing, China
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30
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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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31
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Venna N, Gonzalez RG, Zukerberg LR. Case records of the Massachusetts General Hospital. Case 39-2011. A woman in her 90s with unilateral ptosis. N Engl J Med 2011; 365:2413-22. [PMID: 22187989 DOI: 10.1056/nejmcpc1110048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Nagagopal Venna
- Department of Neurology, Massachusetts General Hospital, and Harvard Medical School, Boston, USA
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Rezania K, Soliven B, Baron J, Lin H, Penumalli V, van Besien K. Myasthenia gravis, an autoimmune manifestation of lymphoma and lymphoproliferative disorders: case reports and review of literature. Leuk Lymphoma 2011; 53:371-80. [PMID: 21864038 DOI: 10.3109/10428194.2011.615426] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kourosh Rezania
- Department of Neurology, University of Chicago Medical Center, Chicago, IL 60637, USA.
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Unusual paraneoplastic syndrome accompanies neuroendocrine tumours of the pancreas. Case Rep Med 2011; 2011:309149. [PMID: 21603138 PMCID: PMC3096302 DOI: 10.1155/2011/309149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Accepted: 03/11/2011] [Indexed: 01/27/2023] Open
Abstract
Neuroendocrine tumours comprise a small percentage of pancreatic neoplasia (10%) (1). Diagnosis of neuroendocrine tumours is difficult, especially if the tumours are small and nonfunctional. CT scans, MRI, and nuclear scans are sufficiently sensitive assessment tools for tumours with diameters of at least 2 cm; otherwise, the sensitivity and specificity of these techniques is less than 50% (2). Myasthenia gravis (MG) is a heterogeneous neuromuscular junction disorder that is primarily caused when antibodies form against the acetylcholine receptors (Ab-AchR). MG can develop in conjunction with neoplasia, making MG a paraneoplastic disease. In those cases, MG is most commonly associated with thymomas and less frequently associated with extrathymic malignancies. The mechanism underlying this paraneoplastic syndrome has been hypothesized to involve an autoimmune response against the tumour cells (3). No published reports have linked malignant pancreatic diseases with MG. Here, we report the case of a young woman, negative for Ab-AchR, with a neuroendocrine tumour in the pancreatic head, who experienced a complete resolution of her MG-like syndrome after surgical enucleation of the tumour.
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Pal J, Rozsa C, Komoly S, Illes Z. Clinical and biological heterogeneity of autoimmune myasthenia gravis. J Neuroimmunol 2011; 231:43-54. [DOI: 10.1016/j.jneuroim.2010.10.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Mays J, Butts CL. Intercommunication between the neuroendocrine and immune systems: focus on myasthenia gravis. Neuroimmunomodulation 2011; 18:320-7. [PMID: 21952684 PMCID: PMC3221261 DOI: 10.1159/000329491] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Crosstalk exists between the nervous, endocrine, and immune systems, and perturbations in these interactions have been associated with disease. This includes production of neuroendocrine factors that alter immune system activity and increase susceptibility to or severity of immune-related conditions, such as myasthenia gravis (MG)--a T-cell-dependent, B-cell-mediated autoimmune disorder. MG results from impairment of transmission to the neuromuscular junction and involves the thymus--especially in early-onset disease, but the exact mechanism by which the thymus impacts disease is unclear. MG afflicts millions of individuals worldwide each year, and both men and women can develop symptoms. However, prevalence and age of onset differs between men and women. Women exhibit higher incidence and earlier age of onset compared to men, and disease fluctuates during pregnancy. This suggests that sex hormones play a role in influencing disease outcome. In this review, we will consider what is known about the manifestation of MG, theories on how different forms of MG are influenced or alleviated by steroid hormones, current treatment options, and what measures could be important to consider in the future.
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Affiliation(s)
- Jacqueline Mays
- Laboratory of Viral Diseases, National Institute of Allergy and Infectious Diseases/National Institutes of Health, US Food and Drug Administration, Bethesda, Md., USA
| | - Cherié L. Butts
- Laboratory of Immunology, Division of Therapeutic Proteins, Office of Biotechnology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Bethesda, Md., USA
- *Cherie Butts, Laboratory of Immunology, Division of Therapeutic Proteins, Office of Biotechnology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, 8800 Rockville Pike (HFD-122), Building 29A, Room 3B19, Bethesda, MD 20892 (USA), Tel. +1 301 827 1843, E-Mail
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36
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Neurology in the European Journal of Neurology. Eur J Neurol 2010. [DOI: 10.1111/j.1468-1331.2010.03248.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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37
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Marx A, Willcox N, Leite MI, Chuang WY, Schalke B, Nix W, Ströbel P. Thymoma and paraneoplastic myasthenia gravis. Autoimmunity 2010; 43:413-27. [PMID: 20380583 DOI: 10.3109/08916930903555935] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Paraneoplastic autoimmune diseases associate occasionally with small cell lung cancers and gynecologic tumors. However, myasthenia gravis (MG) occurs in at least 30% of all patients with thymomas (usually present at MG diagnosis). These epithelial neoplasms almost always have numerous admixed maturing polyclonal T cells (thymocytes). This thymopoiesis-and export of mature CD4(+)T cells-particularly associates with MG, though there are rare/puzzling exceptions in apparently pure epithelial WHO type A thymomas. Other features potentially leading to inefficient self-tolerance induction include defective epithelial expression of the autoimmune regulator (AIRE) gene and/or of major histocompatibility complex class II molecules in thymomas, absence of myoid cells, failure to generate FOXP3(+) regulatory T cells, and genetic polymorphisms affecting T-cell signaling. However, the strong focus on MG/neuromuscular targets remains unexplained and suggests some biased autoantigen expression, T-cell selection, or autoimmunization within thymomas. There must be further clues in the intriguing serological and cellular parallels in some patients with late-onset MG but without thymomas-and in others with AIRE mutations-and in the contrasts with early-onset MG, as discussed here.
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Affiliation(s)
- A Marx
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, D-68135 Mannheim, Germany.
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38
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Seker M, Gozu HI, Oven Ustaalioğlu BB, Sonmez B, Erkal FY, Kocak M, Barisik NO, Orbay E, Sargin M, Sargin H, Boru UT, Yaylaci M. Myasthenia gravis and autoimmune Addison disease in a patient with thymoma. Clin Lung Cancer 2010; 10:367-70. [PMID: 19808197 DOI: 10.3816/clc.2009.n.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The association of thymoma with myasthenia gravis has been well documented. However, the relationship between these two syndromes and Addison disease are very rarely encountered in clinical practice. We report on a 32-year-old man who underwent a resection for thymoma 48 months ago. The diagnosis of Addison disease was made followed by a diagnosis of myasthenia gravis on the basis of a high titer of acetylcholine receptor levels. The treatment of oral prednisolone 7.5 mg/day and oral prostigmine 180 mg/day was initiated. His symptoms and physical signs were improved after this treatment. To our knowledge, this is the fourth reported case of thymoma synchronously associated with myasthenia gravis and Addison disease.
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Affiliation(s)
- Mesut Seker
- Department of Medical Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey.
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A follicular dendritic cell sarcoma of the mediastinum with immature T cells and association with myasthenia gravis. Am J Surg Pathol 2010; 34:742-5. [PMID: 20305533 DOI: 10.1097/pas.0b013e3181d7a2ee] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Follicular dendritic cell (FDC) sarcoma is a very rare neoplasm showing morphologic and phenotypic features of FDCs. It occurs primarily in lymph nodes but also in extranodal sites. So far, there have been no reports on FDC sarcoma associated with myasthenia gravis. In the following we will present a case of an FDC tumor of the mediastinum associated with paraneoplastic myasthenia gravis in a 39-year-old man. The tumor contained a major proportion of immature T cells, which may be connected to this patient's very unusual clinical presentation with autoimmune phenomena. Extranodal FDC sarcomas still seem hardly noticed, and their clinical and pathologic characteristics remain to be better defined.
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40
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Masroujeh R, Otrock ZK, Yamout B, Jabbour MN, Bazarbachi A. Myasthenia gravis developing in a patient with CNS lymphoma. Int J Hematol 2010; 91:522-4. [DOI: 10.1007/s12185-010-0503-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 01/04/2010] [Accepted: 01/13/2010] [Indexed: 11/29/2022]
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Abstract
Current therapy for myasthenia gravis is directed towards generalized modulation and suppression of the immune system. These approaches have been extensively studied and are effective in many patients with myasthenia, but at the cost of significant adverse effects due to the global effects on the immune system. Future directions in therapy are geared towards focused immunotherapies that aim to improve outcomes while lessening the burden of side effects. This paper reviews both the current accepted treatments for myasthenia gravis as well as promising targeted therapies in development.
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Affiliation(s)
- Hans D Katzberg
- Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Vera Bril
- University Health Network, University of Toronto, Toronto, Canada
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42
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Kim WY, Kim H, Jeon YK, Kim CW. Follicular dendritic cell sarcoma with immature T-cell proliferation. Hum Pathol 2009; 41:129-33. [PMID: 19740517 DOI: 10.1016/j.humpath.2009.05.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 04/22/2009] [Accepted: 05/22/2009] [Indexed: 01/28/2023]
Abstract
Follicular dendritic cell sarcoma is characterized by proliferation of spindled to ovoid cells reminiscent of follicular dendritic cells. However, the association of follicular dendritic cell sarcoma with a dense infiltration of immature T cells has not hitherto been reported. We report an unusual case of follicular dendritic cell sarcoma of the mesentery with immature T-cell proliferation in a 68-year-old man. The infiltrating immature T cells demonstrated expression of CD3, CD1a, TdT, and coexpression of CD4 and CD8 by immunohistochemistry. In addition, the patient was subsequently diagnosed with myasthenia gravis and paraneoplastic pemphigus and died of distant metastasis within 2 years after initial diagnosis of follicular dendritic cell sarcoma. The aggressive clinical course of this case contrasts with the indolent course of follicular dendritic cell sarcomas, and thus, the prognostic implications of follicular dendritic cell sarcoma with immature T-cell proliferation require clarification. The complication of myasthenia gravis and paraneoplastic pemphigus may suggest that immature T-cell proliferation has an autoimmunity-related systemic influence.
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Affiliation(s)
- Wook Youn Kim
- Department of Pathology and Tumor Immunity Medical Research Center, Seoul National University College of Medicine, Seoul 110-799, Korea
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43
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Modified Maximal Thymectomy for Thymic Epithelial Tumors: Predictors of Survival and Neurological Outcome in Patients with Thymomatous Myasthenia Gravis. World J Surg 2009; 33:1650-8. [DOI: 10.1007/s00268-009-0097-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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44
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Abstract
Acquired myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction in which patients experience fluctuating skeletal muscle weakness that often affects selected muscle groups preferentially. The target of the autoimmune attack in most cases is the skeletal muscle acetylcholine receptor (AChR), but in others, non-AChR components of the neuromuscular junction, such as the muscle-specific receptor tyrosine kinase, are targeted. The pathophysiological result is muscle endplate dysfunction and consequent fatigable muscle weakness. Clinical presentations vary substantially, both for anti-AChR positive and negative MG, and accurate diagnosis and selection of effective treatment depends on recognition of less typical as well as classic disease phenotypes. Accumulating evidence suggests that clinical MG subgroups might respond differently to treatment. In this Review, we provide current information about the epidemiology, immunopathogenesis, clinical presentations, diagnosis, and treatment of MG, including emerging therapeutic strategies.
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Affiliation(s)
- Matthew N Meriggioli
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA.
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