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Thapa L, Thapa M, Bhattarai S, Shrestha AM, Sharma N, Rai N, Pokharel M, Paudel R. D-penicillamine Induced Myasthenia Gravis in Wilson's Disease: A Case Report. JNMA J Nepal Med Assoc 2022; 60:644-647. [PMID: 36705187 PMCID: PMC9297353 DOI: 10.31729/jnma.7607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/25/2022] [Indexed: 01/31/2023] Open
Abstract
Myasthenia gravis is a neuromuscular junction disorder characterised by fluctuating muscle weakness, improved by using anti-cholinesterase drugs. In addition to the autoimmune aetiology, various factors such as infections, surgery, and drugs are known to precipitate the condition. We report a case of a 15-year-old boy with D-penicillamine-induced myasthenia gravis who presented with facial diplegia, dysphagia, and drooling of saliva, 6 years after the initiation of treatment for Wilson's disease. Therefore, clinicians should be more vigilant while prescribing patients with chelating drugs like D-penicillamine with regular monitoring of the new symptoms and keeping a very low threshold for the suspicion of myasthenia gravis. Keywords d-penicillamine; myasthenia gravis; pyridostigmine; Wilson's disease.
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Affiliation(s)
- Lekhjung Thapa
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal,Correspondence: Dr Lekhjung Thapa, Department of Neurology, National Neuro Centre, Maharajgunj, Kathmandu, Nepal. , Phone: +977-9749370390
| | - Monika Thapa
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Suman Bhattarai
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Abhishek Man Shrestha
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Nooma Sharma
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Nilshan Rai
- KIST Medical College and Teaching Hospital, Imadol, Lalitpur, Nepal
| | - Merina Pokharel
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
| | - Raju Paudel
- Department of Neurology, National Neuro Center, Maharajgunj, Chakrapath, Kathmandu, Nepal
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Sheikh S, Alvi U, Soliven B, Rezania K. Drugs That Induce or Cause Deterioration of Myasthenia Gravis: An Update. J Clin Med 2021; 10:jcm10071537. [PMID: 33917535 PMCID: PMC8038781 DOI: 10.3390/jcm10071537] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 12/20/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neuromuscular disorder which is characterized by presence of antibodies against acetylcholine receptors (AChRs) or other proteins of the postsynaptic membrane resulting in damage to postsynaptic membrane, decreased number of AChRs or blocking of the receptors by autoantibodies. A number of drugs such as immune checkpoint inhibitors, penicillamine, tyrosine kinase inhibitors and interferons may induce de novo MG by altering the immune homeostasis mechanisms which prevent emergence of autoimmune diseases such as MG. Other drugs, especially certain antibiotics, antiarrhythmics, anesthetics and neuromuscular blockers, have deleterious effects on neuromuscular transmission, resulting in increased weakness in MG or MG-like symptoms in patients who do not have MG, with the latter usually being under medical circumstances such as kidney failure. This review summarizes the drugs which can cause de novo MG, MG exacerbation or MG-like symptoms in nonmyasthenic patients.
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Poulas K, Koutsouraki E, Kordas G, Kokla A, Tzartos SJ. Anti-MuSK- and anti-AChR-positive myasthenia gravis induced by d-penicillamine. J Neuroimmunol 2012; 250:94-8. [DOI: 10.1016/j.jneuroim.2012.05.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 03/17/2012] [Accepted: 05/16/2012] [Indexed: 10/28/2022]
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Adelman HM, Winters PR, Mahan CS, Wallach PM. D-penicillamine-induced myasthenia gravis: diagnosis obscured by coexisting chronic obstructive pulmonary disease. Am J Med Sci 1995; 309:191-3. [PMID: 7900739 DOI: 10.1097/00000441-199504000-00001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
D-penicillamine, a drug used to treat rheumatoid arthritis, Wilson's disease, and cystinuria, can cause myasthenia gravis. Fortunately, the myasthenia typically resolves after discontinuation of the drug. The diagnosis may be missed if weakness is blamed on a patient's underlying disease(s), in particular, rheumatoid arthritis. Reported here are the cases of two patients with chronic obstructive lung disease who were taking D-penicillamine for rheumatoid arthritis, then experienced increasing respiratory failure. At first, their problem seemed to stem from chronic lung disease, but further evaluation revealed the cause of the hypoventilation to be D-penicillamine-induced myasthenia gravis.
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Affiliation(s)
- H M Adelman
- Department of Internal Medicine, University of South Florida, College of Medicine, Tampa 33612
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Abstract
Ocular myasthenia is a localized form of myasthenia clinically involving only the extraocular, levator palpebrae superioris, and/or orbicularis oculi muscles. Ocular manifestations can masquerade as a variety of ocular motility disorders, including cranial nerve and gaze palsies. A history of variable and fatiguable muscle weakness suggests this diagnosis, which may be confirmed by the edrophonium (Tensilon) test and acetylcholine receptor antibody titer. Anticholinesterases, corticosteroids and other immunosuppressive agents, and other therapeutic modalities, including thymectomy and plasmapheresis, are used in treatment. As the pathophysiology of myasthenia has been elucidated in recent years, newer treatment strategies have evolved, resulting in a much more favorable prognosis than several decades ago. This review provides historical background, pathophysiology, immuno-genetics, diagnostic testing, and treatment options for ocular myasthenia, as well as a discussion of drug-induced myasthenic syndromes.
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Affiliation(s)
- D A Weinberg
- Neuro-Ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania
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