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Akbari A, Hadizadeh A, Islampanah M, Salavati Nik E, Atkin SL, Sahebkar A. COVID-19, G protein-coupled receptor, and renin-angiotensin system autoantibodies: Systematic review and meta-analysis. Autoimmun Rev 2023; 22:103402. [PMID: 37490975 DOI: 10.1016/j.autrev.2023.103402] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/20/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION There are an increasing number of reports of autoantibodies (AAbs) against host proteins such as G-protein coupled receptors (GPCRs) and the renin-angiotensin system (RAS) in COVID-19 disease. Here we have undertaken a systematic review and meta-analysis of all reports of AAbs against GPCRs and RAS in COVID-19 patients including those with long-COVID or post-COVID symptoms. METHODS PubMed, Embase, Web of Science, and Scopus databases were searched to find papers on the role of GPCR and RAS AAbs in the presence and severity of COVID-19 or post- COVID symptoms available through March 21, 2023. Data on the prevalence of AngII or ACE, comparing AngII or ACE between COVID-19 and non-COVID-19, or comparing AngII or ACE between COVID-19 patients with different disease stages were pooled and a meta-analysed using random- or fixed-effects models were undertaken. RESULTS The search yielded a total of 1042 articles, of which 68 studies were included in this systematic review and nine in the meta-analysis. Among 18 studies that investigated GPCRs and COVID-19 severity, 18 distinct AAbs were detected. In addition, nine AAbs were found in case reports that assessed post- COVID, and 19 AAbs were found in other studies that assessed post- COVID or long- COVID symptoms. Meta-analysis revealed a significantly higher number of seropositive ACE2 AAbs in COVID-19 patients (odds ratio = 7.766 [2.056, 29.208], p = 0.002) and particularly in severe disease (odds ratio = 11.49 [1.04, 126.86], p = 0.046), whereas AngII-AAbs seropositivity was no different between COVID-19 and control subjects (odds ratio = 2.890 [0.546-15.283], p = 0.21). CONCLUSIONS GPCR and RAS AAbs may play an important role in COVID-19 severity, the development of disease progression, long-term symptoms COVID and post- COVID symptoms.
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Affiliation(s)
- Abolfazl Akbari
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Hadizadeh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Muhammad Islampanah
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ensie Salavati Nik
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Stephen L Atkin
- Royal College of Surgeons in Ireland, Bahrain, Adliya, PO Box 15503, Bahrain
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.; Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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Gomez F, Mehra A, Ensrud E, Diedrich D, Laudanski K. COVID-19: a modern trigger for Guillain-Barre syndrome, myasthenia gravis, and small fiber neuropathy. Front Neurosci 2023; 17:1198327. [PMID: 37712090 PMCID: PMC10498773 DOI: 10.3389/fnins.2023.1198327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/31/2023] [Indexed: 09/16/2023] Open
Abstract
COVID-19 infection has had a profound impact on society. During the initial phase of the pandemic, there were several suggestions that COVID-19 may lead to acute and protracted neurologic sequelae. For example, peripheral neuropathies exhibited distinctive features as compared to those observed in critical care illness. The peripheral nervous system, lacking the protection afforded by the blood-brain barrier, has been a particular site of sequelae and complications subsequent to COVID-19 infection, including Guillain-Barre syndrome, myasthenia gravis, and small fiber neuropathy. We will discuss these disorders in terms of their clinical manifestations, diagnosis, and treatment as well as the pathophysiology in relation to COVID-19.
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Affiliation(s)
- Francisco Gomez
- Department of Neurology, University of Missouri, Columbia, MO, United States
| | - Ashir Mehra
- Department of Neurology, University of Missouri, Columbia, MO, United States
| | - Erik Ensrud
- Department of Neurology, University of Missouri, Columbia, MO, United States
| | - Daniel Diedrich
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, United States
| | - Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, United States
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Chaitanuwong P, Moss HE, El Dairi MA. SARS-CoV-2 Infection, Vaccination, and Neuro-Ophthalmic Complications. J Neuroophthalmol 2023; 43:1-4. [PMID: 36790060 PMCID: PMC9924739 DOI: 10.1097/wno.0000000000001812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Affiliation(s)
- Pareena Chaitanuwong
- Ophthalmology Department (PC), Rajavithi Hospital, Ministry of Public Health, Bangkok, Thailand; Department of Ophthalmology (PC), Faculty of Medicine, Rangsit University, Bangkok, Thailand; Department of Ophthalmology (HM) and Neurology and Neurological Sciences (HM), Stanford University School of Medicine, Palo Alto, California; and Department of Ophthalmology (MED), Duke University, Durham, North Carolina
| | - Heather E. Moss
- Ophthalmology Department (PC), Rajavithi Hospital, Ministry of Public Health, Bangkok, Thailand; Department of Ophthalmology (PC), Faculty of Medicine, Rangsit University, Bangkok, Thailand; Department of Ophthalmology (HM) and Neurology and Neurological Sciences (HM), Stanford University School of Medicine, Palo Alto, California; and Department of Ophthalmology (MED), Duke University, Durham, North Carolina
| | - Mays A. El Dairi
- Ophthalmology Department (PC), Rajavithi Hospital, Ministry of Public Health, Bangkok, Thailand; Department of Ophthalmology (PC), Faculty of Medicine, Rangsit University, Bangkok, Thailand; Department of Ophthalmology (HM) and Neurology and Neurological Sciences (HM), Stanford University School of Medicine, Palo Alto, California; and Department of Ophthalmology (MED), Duke University, Durham, North Carolina
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Kanatani S, Yamaguchi H, Oikawa S, Tokumoto S, Tomioka K, Nishiyama M, Nozu K, Nagase H. A Case of Generalized Myasthenia Gravis Exacerbated by COVID-19. JOURNAL OF PEDIATRIC NEUROLOGY 2023. [DOI: 10.1055/s-0043-1761932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
AbstractMyasthenia gravis (MG) is a rare, long-term neuromuscular disorder that can affect individuals of any age. In Japan, the Omicron variant of coronavirus disease 2019 (COVID-19) began spreading in 2022, and many cases of neurological symptoms caused by the virus have been reported. Although COVID-19 has been reported to exacerbate MG in adults, there are no reports on the effects of COVID-19 on the MG symptoms of pediatric patients. We report the case of a 6-year-old girl with a 3-year history of MG who presented to our hospital with symptom exacerbation after COVID-19 infection. Four days before admission, she developed fever with a runny nose and cough. Three days before admission, she developed severe bilateral blepharoptosis and progressive limb weakness, and 2 days before admission, she was diagnosed with COVID-19 by SARS-CoV-2 antigen test. Physical examination revealed moderate blepharoptosis and mild bilateral upper and lower limb weakness. We diagnosed her with worsening MG due to COVID-19, and she was administered 400 mg/kg intravenous immunoglobulin (IVIG) daily for 5 days with continued oral corticosteroids and tacrolimus. The patient's symptoms improved promptly after admission and, at discharge 7 days after admission, her symptoms had significantly improved. During the 1-month outpatient follow-up period, she remained stable and the anti-acetylcholine receptor (AchR) antibody level was reduced to 14.6 nmol/L (from 18.5 nmol/L on admission). Our case suggests that COVID-19 exacerbates MG in both children and adults.
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Affiliation(s)
- Shingo Kanatani
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Hiroshi Yamaguchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shizuka Oikawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shoichi Tokumoto
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Kazumi Tomioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Masahiro Nishiyama
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Hiroaki Nagase
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
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Muacevic A, Adler JR, Roy M. A Case Report and Literature Review of New-Onset Myasthenia Gravis After COVID-19 Infection. Cureus 2022; 14:e33048. [PMID: 36721575 PMCID: PMC9881688 DOI: 10.7759/cureus.33048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2022] [Indexed: 12/29/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disorder affecting the neuromuscular junction caused by a B-cell-mediated, T-cell-dependent immunologic attack at the end plate of the postsynaptic membrane. Attack on muscle acetylcholine receptors (AChR) of the postsynaptic membrane due to the AChR, muscle-specific tyrosine kinase, or lipoprotein receptor-related peptide 4 antibodies lead to symptoms of painless, fluctuating weakness of muscle groups and often begins with ocular signs and symptoms. Coronavirus disease 2019 (COVID-19) is an acute respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus closely related to SARS-CoV. Serious neurologic complications are infrequent and diverse with reported cases of stroke, encephalitis/meningitis, Guillain-Barré syndrome, acute disseminated encephalomyelitis, ataxia, and unspecified limb weakness. MG is a rarely reported sequela of COVID-19 infection. To date, there are 15 reported cases of post-COVID-19 MG. In this article, we present a case of post-COVID-19 MG and a concise review of other reported cases. An 83-year-old Caucasian male with a medical history of atrial fibrillation status post-ablation and non-ischemic cardiomyopathy was initially admitted for COVID-19 pneumonia. He was treated with remdesivir, convalescent plasma, and supplemental oxygen therapy but did not require invasive mechanical intubation. One month after discharge, he started experiencing fatigue with muscle weakness and progressive dyspnea. He progressed to develop dysphonia, especially at the end of the day. After extensive workup, he was diagnosed with MG with a positive antibody against the AChR. The chronological events of developing slowly worsening muscular weakness after recovering from COVID-19 infection and positive AChR antibody led to the diagnosis of post-COVID-19 new-onset MG. Post-COVID-19 fatigue, long-term use of steroids, and intensive care unit-related physical deconditioning can be confounders in the clinical presentation of post-COVID-19 new-onset MG. Careful history-taking and meticulous assessment of chronological events are needed to diagnose this rare entity.
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Tugasworo D, Kurnianto A, Retnaningsih, Andhitara Y, Ardhini R, Budiman J. The relationship between myasthenia gravis and COVID-19: a systematic review. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022; 58:83. [PMID: 35818475 PMCID: PMC9261189 DOI: 10.1186/s41983-022-00516-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Viral infection such as coronavirus disease 2019 (COVID-19) can exacerbate and aggravate neurological disorders due to autoimmune etiology like myasthenia gravis (MG). Experimental therapies used in COVID-19 are also factors that can cause the worsening of MG symptoms. This review aimed to assess and conclude the research-based study systematically to analyze the relationship of MG and COVID-19. Method This study was conducted in accordance to Cochrane handbook for systematic reviews and the guideline of preferred reporting items for systematic review and meta-analysis (PRISMA) and synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. Inclusion criteria in this review were primary studies of every design, articles published in English around January 2000–October 2021, and the study used human as subject. A systematic literature finding was applied in 15 electronic scientific resources. The authors evaluated the study quality and risk of bias of each retrieved article. Results The authors found the study through electronic scientific resources that met inclusion and exclusion criteria. The authors evaluated 362 articles identified in literature searching, 22 articles met the criteria for this review and then underwent the evaluation of study quality and risk of bias. Conclusion COVID-19 infection can increase the risk of new-onset MG, myasthenic crisis, respiratory failure, and mortality rate due to cytokine storm in MG patients. The management of COVID-19 patients with MG is tailored to each person and based on national guidelines and local expert recommendations.
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Dinkin M, Sathi S. Efferent neuro-ophthalmic complications of coronavirus disease 2019. Curr Opin Ophthalmol 2022; 33:471-484. [PMID: 36165417 DOI: 10.1097/icu.0000000000000904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW We set out to describe efferent neuro-ophthalmological complications that have been reported in association with coronavirus disease 2019 (COVID-19) infection. We describe syndromes affecting ocular motility and elaborate on mechanisms of disease, including para-infectious inflammation, hypercoagulability, endothelial damage, and direct neurotropic viral invasion. Despite global vaccination programs, COVID-19 continues to pose an international threat that may rarely result in diplopia or nystagmus. RECENT FINDINGS Efferent complications include cranial nerve palsies leading to diplopia, either isolated or in association with Miller Fisher syndrome. Nystagmus has been observed in the setting of hemorrhagic acute necrotizing encephalopathy and brainstem infarcts, and opsoclonus syndrome has been described. SUMMARY Observed neuro-ophthalmic associations need to be confirmed through larger comparative studies. Meanwhile, the range of possible complications should be recognized by neurologists and ophthalmologists alike, to facilitate faster diagnosis and treatment of both COVID-19 and its neuro-ophthalmic manifestations.
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Affiliation(s)
- Marc Dinkin
- Departments of Ophthalmology and Neurology, Weill Cornell Medical College
| | - Swetha Sathi
- M2, Weill Cornell Medical College, New York, New York, USA
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Yavuz P, Demir OO, Ozsurekci Y, Ozen S, Anlar B, Haliloglu G. New-Onset Ocular Myasthenia after Multisystem Inflammatory Syndrome in Children. J Pediatr 2022; 245:213-216. [PMID: 35231493 PMCID: PMC8882031 DOI: 10.1016/j.jpeds.2022.02.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/13/2022]
Abstract
Neurologic complications have been associated with multisystem inflammatory syndrome in children, possibly involving autoimmune mechanisms. Here, we report a 6-year-old girl who developed myasthenia 11 weeks after severe acute respiratory syndrome coronavirus 2 infection and 8 weeks after the onset of severe multisystem inflammatory syndrome in children.
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Affiliation(s)
- Pınar Yavuz
- Division of Pediatric Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Osman Oguz Demir
- Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Yasemin Ozsurekci
- Division of Pediatric Infectious Diseases, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Seza Ozen
- Division of Pediatric Rheumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Banu Anlar
- Division of Pediatric Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Goknur Haliloglu
- Division of Pediatric Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
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A Comprehensive Review of Neuromuscular Manifestations of COVID-19 and Management of Pre-Existing Neuromuscular Disorders in Children. J Clin Med 2022; 11:jcm11040934. [PMID: 35207206 PMCID: PMC8876161 DOI: 10.3390/jcm11040934] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/01/2022] [Accepted: 02/07/2022] [Indexed: 02/04/2023] Open
Abstract
Since the emergence of SARS-CoV-2, several studies have been published describing neuromuscular manifestations of the disease, as well as management of pre-existing pediatric neuromuscular disorders during the COVID-19 pandemic. These disorders include muscular dystrophies, myasthenic syndromes, peripheral nerve disorders, and spinal muscular atrophy. Such patients are a vulnerable population due to frequent complications such as scoliosis, cardiomyopathy, and restrictive lung disease that put them at risk of severe complications of COVID-19. In this review, neuromuscular manifestations of COVID-19 in children and the management of pre-existing pediatric neuromuscular disorders during the COVID-19 pandemic are discussed. We also review strategies to alleviate pandemic-associated disruptions in clinical care and research, including the emerging role of telemedicine and telerehabilitation to address the continued special needs of these patients.
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Kopańska M, Batoryna M, Bartman P, Szczygielski J, Banaś-Ząbczyk A. Disorders of the Cholinergic System in COVID-19 Era-A Review of the Latest Research. Int J Mol Sci 2022; 23:ijms23020672. [PMID: 35054856 PMCID: PMC8775685 DOI: 10.3390/ijms23020672] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/02/2022] [Accepted: 01/04/2022] [Indexed: 02/06/2023] Open
Abstract
The appearance of the SARS-CoV-2 virus initiated many studies on the effects of the virus on the human body. So far, its negative influence on the functioning of many morphological and physiological units, including the nervous system, has been demonstrated. Consequently, research has been conducted on the changes that SARS-CoV-2 may cause in the cholinergic system. The aim of this study is to review the latest research from the years 2020/2021 regarding disorders in the cholinergic system caused by the SARS-CoV-2 virus. As a result of the research, it was found that the presence of the COVID-19 virus disrupts the activity of the cholinergic system, for example, causing the development of myasthenia gravis or a change in acetylcholine activity. The SARS-CoV-2 spike protein has a sequence similar to neurotoxins, capable of binding nicotinic acetylcholine receptors (nAChR). This may be proof that SARS-CoV-2 can bind nAChR. Nicotine and caffeine have similar structures to antiviral drugs, capable of binding angiotensin-converting enzyme 2 (ACE 2) epitopes that are recognized by SARS-CoV-2, with the potential to inhibit the formation of the ACE 2/SARS-CoV-2 complex. The blocking is enhanced when nicotine and caffeine are used together with antiviral drugs. This is proof that nAChR agonists can be used along with antiviral drugs in COVID-19 therapy. As a result, it is possible to develop COVID-19 therapies that use these compounds to reduce cytokine production. Another promising therapy is non-invasive stimulation of the vagus nerve, which soothes the body’s cytokine storm. Research on the influence of COVID-19 on the cholinergic system is an area that should continue to be developed as there is a need for further research. It can be firmly stated that COVID-19 causes a dysregulation of the cholinergic system, which leads to a need for further research, because there are many promising therapies that will prevent the SARS-CoV-2 virus from binding to the nicotinic receptor. There is a need for further research, both in vitro and in vivo. It should be noted that in the functioning of the cholinergic system and its connection with the activity of the COVID-19 virus, there might be many promising dependencies and solutions.
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Affiliation(s)
- Marta Kopańska
- Department of Pathophysiology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-959 Rzeszow, Poland
- Correspondence:
| | - Marta Batoryna
- Sensusmed, Psychotherapy and Neurorehabilitation Center, 30-084 Cracow, Poland;
| | - Paulina Bartman
- Students Science Club “Reh-Tech”, University of Rzeszow, 35-959 Rzeszow, Poland;
| | - Jacek Szczygielski
- Department of Neurosurgery, Institute of Medical Sciences, Medical College of Rzeszow University, 35-959 Rzeszow, Poland;
- Department of Neurosurgery, Faculty of Medicine, Saarland University, 66424 Homburg, Germany
| | - Agnieszka Banaś-Ząbczyk
- Departament of Biology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-959 Rzeszow, Poland;
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Zhou Q, Zhou R, Yang H, Yang H. To Be or Not To Be Vaccinated: That Is a Question in Myasthenia Gravis. Front Immunol 2021; 12:733418. [PMID: 34603311 PMCID: PMC8485039 DOI: 10.3389/fimmu.2021.733418] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/01/2021] [Indexed: 01/04/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by muscle weakness and abnormal fatigability due to the antibodies against postsynaptic receptors. Despite the individual discrepancy, patients with MG share common muscle weakness, autoimmune dysfunction, and immunosuppressive treatment, which predispose them to infections that can trigger or exacerbate MG. Vaccination, as a mainstay of prophylaxis, is a major management strategy. However, the past years have seen growth in vaccine hesitancy, owing to safety and efficacy concerns. Ironically, vaccines, serving as an essential and effective means of defense, may induce similar immune cross-reactivity to what they are meant to prevent. Herein, we outline the progress in vaccination, review the current status, and postulate the clinical association among MG, vaccination, and immunosuppression. We also address safety and efficacy concerns of vaccination in MG, in relation to COVID-19. Since only a handful of studies have reported vaccination in individuals with MG, we further review the current clinical studies and guidelines in rheumatic diseases. Overall, our reviews offer a reference to guide future vaccine clinical decision-making and improve the management of MG patients.
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Affiliation(s)
| | | | | | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
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