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de Souza A, Raj R. De Novo Onset of Myasthenia Gravis after Kidney Transplantation. Case Rep Transplant 2024; 2024:5473862. [PMID: 38323164 PMCID: PMC10843868 DOI: 10.1155/2024/5473862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/02/2024] [Accepted: 01/18/2024] [Indexed: 02/08/2024] Open
Abstract
Myasthenia gravis occurring de novo after kidney transplantation is a rare course of severe muscle weakness. A 57-year-old female on treatment with peritoneal dialysis following polycystic kidney disease received a renal transplant with standard basiliximab induction. She had no preceding history of neuromuscular problems. Three months after transplant she presented with progressive weakness and fatigability, finally needing a wheelchair to mobilise. Graft function was stable. Examination revealed patchy limb weakness, worsening on repeated exercise. There were no abnormalities in cranial nerves, reflexes, or sensation. Electromyography was normal, but repetitive nerve stimulation studies showed a postsynaptic neuromuscular transmission defect suggestive of myasthenia gravis. Serological testing revealed no putative antibodies. Initial treatment with pyridostigmine was not tolerated. Following an episode of hospitalisation with severe limb weakness, she received intravenous immunoglobulin and showed dramatic improvement, which persisted over the next few weeks. Approximately 6 months later, she had a relapse of her symptoms, which once again responded to intravenous immunoglobulin therapy. De novo myasthenia gravis after transplantation is a rare entity, infrequently reported in the literature. This illness is surprising since immunosuppression after transplant is usually sufficient to prevent immune-mediated disease. This patient had no history of similar illnesses. Delayed physical recovery after major surgery such as renal transplantation is often attributed to other causes such as deconditioning, and patients are often prescribed physiotherapy as a response. In this patient, the profound unexplained weakness that persisted for several weeks after transplant prompted referral to the neurologist, which enabled this rare diagnosis to be made. This story highlights the need to monitor unexpected symptoms closely and to consider a wide differential diagnosis when improvement after transplant is not along usual expected lines. Finally, this case also illustrates the benefits of multidisciplinary involvement in the care of these complex patients.
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Affiliation(s)
- Aaron de Souza
- College of Health & Medicine, University of Tasmania & Launceston General Hospital, Launceston, Australia
| | - Rajesh Raj
- College of Health & Medicine, University of Tasmania & Launceston General Hospital, Launceston, Australia
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Stem Cell Therapy in Neuroimmunological Diseases and Its Potential Neuroimmunological Complications. Cells 2022; 11:cells11142165. [PMID: 35883607 PMCID: PMC9318423 DOI: 10.3390/cells11142165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/03/2022] [Accepted: 07/06/2022] [Indexed: 12/29/2022] Open
Abstract
Background: Since the 1990s, transplantations of hematopoietic and mesenchymal stem cells (HSCT and MSCT) and dendritic cell (DCT) have been investigated for the treatment of neurological autoimmune disorders (NADs). With the growing number of transplanted patients, awareness of neuroimmunolgical complications has increased. Therefore, an overview of SCT for the most common NADs and reports of secondary immunity after SCT is provided. Methods: For this narrative review, a literature search of the PubMed database was performed. A total of 86 articles reporting on different SCTs in NADs and 61 articles dealing with immune-mediated neurological complications after SCT were included. For multiple sclerosis (MS), only registered trials and phase I/II or II studies were considered, whereas all available articles on other disorders were included. The different transplantation procedures and efficacy and safety data are presented. Results: In MS patients, beneficial effects of HSCT, MSCT, and DCT with a decrease in disability and stabilization of disease activity have been reported. These effects were also shown in other NADs mainly in case reports. In seven of 132 reported patients with immune-mediated neurological complications, the outcome was fatal. Conclusions: Phase III trials are ongoing for MS, but the role of SCT in other NADs is currently limited to refractory patients due to occasional serious complications.
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Li S, Cao Y, Li L, Zhang H, Lu X, Bo C, Kong X, Liu Z, Chen L, Liu P, Jiao Y, Wang J, Ning S, Wang L. Building the drug-GO function network to screen significant candidate drugs for myasthenia gravis. PLoS One 2019; 14:e0214857. [PMID: 30947317 PMCID: PMC6448860 DOI: 10.1371/journal.pone.0214857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 03/22/2019] [Indexed: 12/17/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease. In recent years, considerable evidence has indicated that Gene Ontology (GO) functions, especially GO-biological processes, have important effects on the mechanisms and treatments of different diseases. However, the roles of GO functions in the pathogenesis and treatment of MG have not been well studied. This study aimed to uncover the potential important roles of risk-related GO functions and to screen significant candidate drugs related to GO functions for MG. Based on MG risk genes, 238 risk GO functions and 42 drugs were identified. Through constructing a GO function network, we discovered that positive regulation of NF-kappaB transcription factor activity (GO:0051092) may be one of the most important GO functions in the mechanism of MG. Furthermore, we built a drug-GO function network to help evaluate the latent relationship between drugs and GO functions. According to the drug-GO function network, 5 candidate drugs showing promise for treating MG were identified. Indeed, 2 out of 5 candidate drugs have been investigated to treat MG. Through functional enrichment analysis, we found that the mechanisms between 5 candidate drugs and associated GO functions may involve two vital pathways, specifically hsa05332 (graft-versus-host disease) and hsa04940 (type I diabetes mellitus). More interestingly, most of the processes in these two pathways were consistent. Our study will not only reveal a new perspective on the mechanisms and novel treatment strategies of MG, but also will provide strong support for research on GO functions.
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Affiliation(s)
- Shuang Li
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Yuze Cao
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lei Li
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Huixue Zhang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Xiaoyu Lu
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Chunrui Bo
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Xiaotong Kong
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Zhaojun Liu
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Lixia Chen
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Peifang Liu
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Yang Jiao
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Jianjian Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
- * E-mail: (LW); (SN); (JW)
| | - Shangwei Ning
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Heilongjiang Province, China
- * E-mail: (LW); (SN); (JW)
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang Province, China
- * E-mail: (LW); (SN); (JW)
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Kim K, Lee HJ, Park S, Hwang Y, Kim YW, Kim YT. Successful Lung Transplantation in a Patient with Myasthenia Gravis. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 50:382-385. [PMID: 29124031 PMCID: PMC5628967 DOI: 10.5090/kjtcs.2017.50.5.382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/20/2017] [Accepted: 01/23/2017] [Indexed: 12/05/2022]
Abstract
A 47-year-old man with myasthenia gravis (MG) was admitted for a lung transplant. He had bronchiolitis obliterans after allogeneic hematopoietic stem cell transplantation due to acute myeloid leukemia. MG developed after stem cell transplantation. Bilateral sequential lung transplantations and a total thymectomy were performed. The patient underwent right diaphragmatic plication simultaneously due to preoperatively diagnosed right diaphragmatic paralysis. A tracheostomy was performed and bilevel positive airway pressure (BiPAP) was applied on postoperative days 8 and 9, respectively. The patient was transferred to the general ward on postoperative day 12, successfully weaned off BiPAP on postoperative day 18, and finally discharged on postoperative day 62.
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Affiliation(s)
- Kangmin Kim
- Department of Thoracic and Cardiovascular Surgery, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - Hyun Joo Lee
- Department of Thoracic and Cardiovascular Surgery, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - Samina Park
- Department of Thoracic and Cardiovascular Surgery, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - Yoohwa Hwang
- Department of Thoracic and Cardiovascular Surgery, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - Young Whan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
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Abstract
Myasthenia gravis (MG) is the most common disorder of neuromuscular transmission and is a prototypical autoimmune disorder. Most patients with MG are successfully treated with acetylcholinesterase inhibitors, corticosteroids, and/or steroid sparing agents such as azathioprine and mycophenolate mofetil. There is a small subset of patients, however, with treatment-refractory disease. In these cases, medications such as rituximab, high-dose cyclophosphamide, and eculizumab may be used. Thymectomy (in some cases repeat thymectomy) is another option in selected patients. Studies evaluating these and other forms of therapy in treatment-refractory MG are reviewed.
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Affiliation(s)
- Nicholas J Silvestri
- Department of Neurology, State University of New York, Buffalo School of Medicine and Biomedical Sciences, Buffalo General Medical Center, Buffalo, NY
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Pustavoitau A, Bhardwaj A, Stevens R. Analytic Review: Neurological Complications of Transplantation. J Intensive Care Med 2011; 26:209-22. [DOI: 10.1177/0885066610389549] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Recipients of solid organ or hematopoietic cell transplants are at risk of life-threatening neurological disorders including encephalopathy, seizures, infections and tumors of the central nervous system, stroke, central pontine myelinolysis, and neuromuscular disorders—often requiring admission to, or occurring in, the intensive care unit (ICU). Many of these complications are linked directly or indirectly to immunosuppressive therapy. However, neurological disorders may also result from graft versus host disease, or be an expression of the underlying disease which prompted transplantation, as well as injury induced during radiation, chemotherapy, surgery, and ICU stay. In rare cases, neuroinfectious pathogens may be transmitted with the transplanted tissue or organ. Diagnosis may be a challenge because clinical symptoms and findings on neuroimaging lack specificity, and a biological specimen or tissue diagnosis is often needed for definitive diagnosis. Management is centered on preventing further neurological injury, etiology-targeted therapy, and balancing the benefits and toxicities of specific immunosuppressive agents.
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Affiliation(s)
- Aliaksei Pustavoitau
- Departments of Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anish Bhardwaj
- Departments of Neurology and Neurological Surgery, Tufts University School of Medicine, Boston, MA, USA,
| | - Robert Stevens
- Departments of Anesthesiology Critical Care Medicine, Neurology, Neurosurgery, and Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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White AC, Terrin N, Miller KB, Ryan HF. Impaired Respiratory and Skeletal Muscle Strength in Patients Prior to Hematopoietic Stem-Cell Transplantation. Chest 2005; 128:145-52. [PMID: 16002928 DOI: 10.1378/chest.128.1.145] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES The primary aim was to determine if respiratory and skeletal muscle strength and submaximal exercise capacity were reduced in subjects prior to sibling- or unrelated-donor hematopoietic stem-cell transplantation (HSCT). DESIGN Prospective observational study. SETTING Tufts-New England Medical Center, a tertiary referral center in Boston, MA. PATIENTS All patients (n = 56) undergoing either sibling- or unrelated-donor HSCT from January 1, 2002, to December 31, 2002. MEASUREMENTS Demographic data, chemotherapy burden, pulmonary function tests (PFTs), maximal inspiratory muscle strength (PImax), maximal expiratory muscle strength (PEmax), dominant hand grip strength (GS), 6-min walk test (6MWT), and survival as of May 21, 2004. RESULTS PImax was reduced to < 80% predicted in 42% of subjects and to < 60% predicted in 18% of subjects. PEmax was reduced to < 80% predicted in 89% of subjects and to < 60% of predicted in 80% of subjects. A significant correlation was observed between PImax and PEmax (r = 0.65, p < 0.0001). GS was reduced to < 80% predicted in 39% of subjects and < 60% predicted in 15% of subjects. The 6MWT was reduced to < 80% predicted in 58% of subjects and to < 60% predicted in 9.6% of subjects. Diffusing capacity of the lung for carbon monoxide (Dlco) was the only PFT that was significantly correlated with 6MWT distance (r = 0.44, p = 0.015). The mean calculated load of chemotherapy was 14.8 +/- 16.5 U (+/- SD). The mean time elapsed from date of hematologic diagnosis to date of HSCT was 874 +/- 1,109 days. The median survival of the cohort was 374 days (95% confidence interval, 177 to 665 days). Respiratory or skeletal muscle strength, 6MWT distance, or calculated burden of chemotherapy did not predict survival. CONCLUSIONS Respiratory and skeletal muscle strength and submaximal exercise capacity are reduced in a significant percentage of patients prior to undergoing HSCT. These observations may help explain musculoskeletal weakness that has been reported in the posttransplant period.
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Affiliation(s)
- Alexander C White
- Pulmonary, Critical Care and Sleep Division, New England Medical Center, NEMC #369, 750 Washington St, Boston, MA 02111, USA.
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Stevens AM. Foreign cells in polymyositis: Could stem cell transplantation and pregnancy-derived chimerism lead to the same disease? Curr Rheumatol Rep 2003; 5:437-44. [PMID: 14609488 DOI: 10.1007/s11926-003-0054-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A growing number of hematopoietic stem cell transplantation centers have reported that patients with chronic graft versus host disease (GVHD) can develop polymyositis (PM). GVHD-PM is similar to idiopathic PM in signs, symptoms, laboratory values, electromyography, radiography, and histology, suggesting that the two conditions may share a similar mechanism in pathogenesis. In chronic GVHD-PM, interactions between allogeneic donor cells and host cells lead to chronic inflammation. In idiopathic PM, the foreign cells could be partially human leukocyte antigen-matched maternal or fetal cells acquired during pregnancy. Thus, PM can be added to the list of potentially allo-autoimmune diseases in which pregnancy-derived microchimerism may play a role.
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Affiliation(s)
- Anne M Stevens
- Immunogenetics Department, Fred Hutchinson Cancer Research Center, PO Box 19024, D2-100, 1100 Fairview Avenue NE, Seattle, WA 98109, USA.
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Bunyan R, Gardner B, Baize T, Mudd L, Herzig R, Hasan A, Swenson M. Myasthenia Gravis After Bone Marrow Transplantation for Chronic Myelocytic Leukemia: Relationship to Chronic Graft versus Host Disease. J Clin Neuromuscul Dis 2002; 3:136-137. [PMID: 19078669 DOI: 10.1097/00131402-200203000-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Reem Bunyan
- Departments of Neurology and Hematology/Oncology University of Louisville Louisville, Kentucky, U.S.A
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Leano AM, Miller K, White AC. Chronic graft-versus-host disease-related polymyositis as a cause of respiratory failure following allogeneic bone marrow transplant. Bone Marrow Transplant 2000; 26:1117-20. [PMID: 11108314 DOI: 10.1038/sj.bmt.1702688] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
An unusual case of respiratory failure and dropped head syndrome as a complication of severe chronic graft-versus-host disease (GVHD)-related polymyositis is described. The patient required tracheostomy and mechanical ventilation but recovered following treatment with aggressive immunosuppression and intensive rehabilitation. The differential diagnoses of muscle weakness in the bone marrow transplant (BMT) patient and the dropped head syndrome are both discussed. To our knowledge, this is the first reported case of respiratory failure requiring mechanical ventilation occurring as a complication of GVHD-related polymyositis.
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Affiliation(s)
- A M Leano
- Department of Medicine, New England Medical Center, Tufts University School of Medicine, Tupper Research Institute, Boston, MA 02111, USA
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