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Liu S, Hong Y, Wang BR, Wei ZQ, Zhao HD, Jiang T, Zhang YD, Shi JQ. The presence and clinical significance of autoantibodies in amyotrophic lateral sclerosis: a narrative review. Neurol Sci 2024:10.1007/s10072-024-07581-x. [PMID: 38733435 DOI: 10.1007/s10072-024-07581-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
Amyotrophic lateral sclerosis (ALS) is a debilitating and rapidly fatal neurodegenerative disease, which is characterized by the selective loss of the upper and lower motor neurons. The pathogenesis of ALS remains to be elucidated and has been connected to genetic, environmental and immune conditions. Evidence from clinical and experimental studies has suggested that the immune system played an important role in ALS pathophysiology. Autoantibodies are essential components of the immune system. Several autoantibodies directed at antigens associated with ALS pathogenesis have been identified in the serum and/or cerebrospinal fluid of ALS patients. The aim of this review is to summarize the presence and clinical significance of autoantibodies in ALS.
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Affiliation(s)
- Shen Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, 210006, PR China
| | - Ye Hong
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, 210006, PR China
| | - Bian-Rong Wang
- Department of Neurology, Geriatric Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210006, PR China
| | - Zi-Qiao Wei
- The Second Clinical Medical School of Nanjing Medical University, Nanjing, Jiangsu Province, 211166, PR China
| | - Hong-Dong Zhao
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, 210006, PR China
| | - Teng Jiang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, 210006, PR China
| | - Ying-Dong Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, 210006, PR China
| | - Jian-Quan Shi
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, 210006, PR China.
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Kovrazhkina EA, Serdyuk AV, Razinskaya OD, Shurdumova MH, Vyatkina NV, Baranova EA. [Myasthenic syndrome in a patient with end-stage amyotrophic lateral sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:102-107. [PMID: 37490673 DOI: 10.17116/jnevro2023123071102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) and myasthenia gravis are diseases with similar clinical features but different prognosis and approach to treatment. It is possible as an extremely rare combination of these diseases, as well as myasthenia gravis with signs of ALS (MuSK-positive), as well as ALS, accompanied by myasthenic syndrome. Latter option is the most common. Myasthenic syndrome accompanying the ALS characterized by pathological muscle fatigue signs, symptoms variability during the day, partial sensitivity to neostigmine, M-wave decrements detection during electromyographyc study. We present a case of a patient with terminal ALS and myasthenic syndrome. The main pathogenesis theories of this condition and the differential diagnosis of ALS and myasthenia gravis are discussed.
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Affiliation(s)
- E A Kovrazhkina
- Federal Center for Brain and Neurotechnology, Moscow, Russia
| | - A V Serdyuk
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - O D Razinskaya
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M H Shurdumova
- Pirogov Russian National Research Medical University, Moscow, Russia
- Moscow City Clinical Hospital No. 31, Moscow, Russia
| | - N V Vyatkina
- Moscow City Clinical Hospital No. 31, Moscow, Russia
| | - E A Baranova
- Federal Center for Brain and Neurotechnology, Moscow, Russia
- Kazan State Medical Academy, Kazan, Russia
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3
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Benvenga S, Antonelli A, Fallahi P, Bonanno C, Rodolico C, Guarneri F. Amino acid sequence homology between thyroid autoantigens and central nervous system proteins: Implications for the steroid-responsive encephalopathy associated with autoimmune thyroiditis. J Clin Transl Endocrinol 2021; 26:100274. [PMID: 34849350 PMCID: PMC8609095 DOI: 10.1016/j.jcte.2021.100274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 10/15/2021] [Accepted: 10/27/2021] [Indexed: 11/13/2022] Open
Abstract
Alpha-enolase, aldehyde reductase-I and dimethylargininase-I are SREAT autoantigens. Molecular mimicry between thyroid and CNS autoantigens is hypothesized in SREAT. Homology with TSH-R, Tg and TPO exists for 6, 27 and 47 of 46,809 CNS-proteins. The above homologies are often in epitope-containing parts of thyroid autoantigens. Most of the above proteins are expressed in CNS regions which are altered in SREAT.
A few patients with Hashimoto’s thyroiditis or Graves’ disease develop a multiform syndrome of the central nervous system (CNS) termed Hashimoto’s encephalopathy or steroid-responsive encephalopathy associated with autoimmune thyroid disease (HE/SREAT). They have high levels of thyroid autoantibodies (TgAb, TPOAb and/or TSH-R-Ab) in blood and cerebrospinal fluid. Autoantibodies against alpha-enolase, aldehyde reductase-I (AKRIA) and/or dimethylargininase-I (DDAHI), proteins expressed in the CNS among other tissues, were detected in the blood and, when searched, in the cerebrospinal fluid of HE/SREAT patients. Recently, we reported that alpha-enolase, AKRIA and DDAHI share local sequence homology with each of the three autoantigens (TgAb, TPOAb, TSH-R-Ab), often in epitope-containing segments of the thyroid autoantigens. We hypothesized that there might be additional CNS-expressed proteins homologous to thyroid autoantigens, possibly overlapping known epitopes of the thyroid autoantigens. We used bioinformatic methods to address this hypothesis. Six, 27 and 47 of 46,809 CNS-expressed proteins share homology with TSH-R, Tg and TPO, respectively. The homologous regions often contain epitopes, and some match regions of thyroid autoantigens which have homology with alpha-enolase, AKRIA and/or DDAHI. Several of the aforementioned proteins are present in CNS areas that show abnormalities at neuroimaging in HE/SREAT patients. Furthermore, autoantibodies against some of the said six, 27 and 47 proteins were reported to be associated with a number of autoimmune diseases. Not only we validated our hypothesis, but we think that such a variety of potential CNS targets for thyroid Ab against epitopes contained in regions that have local homology with CNS proteins may explain the polymorphic phenotypes of HE/SREAT. Only when elevated amounts of these Ab are synthesized and trespass the blood-brain barrier, HE/SREAT appears. This might explain why HE/SREAT is so relatively rare.
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Amor S, Nutma E, Marzin M, Puentes F. Imaging immunological processes from blood to brain in amyotrophic lateral sclerosis. Clin Exp Immunol 2021; 206:301-313. [PMID: 34510431 PMCID: PMC8561688 DOI: 10.1111/cei.13660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/18/2021] [Accepted: 08/29/2021] [Indexed: 12/12/2022] Open
Abstract
Neuropathology studies of amyotrophic lateral sclerosis (ALS) and animal models of ALS reveal a strong association between aberrant protein accumulation and motor neurone damage, as well as activated microglia and astrocytes. While the role of neuroinflammation in the pathology of ALS is unclear, imaging studies of the central nervous system (CNS) support the idea that innate immune activation occurs early in disease in both humans and rodent models of ALS. In addition, emerging studies also reveal changes in monocytes, macrophages and lymphocytes in peripheral blood as well as at the neuromuscular junction. To more clearly understand the association of neuroinflammation (innate and adaptive) with disease progression, the use of biomarkers and imaging modalities allow monitoring of immune parameters in the disease process. Such approaches are important for patient stratification, selection and inclusion in clinical trials, as well as to provide readouts of response to therapy. Here, we discuss the different imaging modalities, e.g. magnetic resonance imaging, magnetic resonance spectroscopy and positron emission tomography as well as other approaches, including biomarkers of inflammation in ALS, that aid the understanding of the underlying immune mechanisms associated with motor neurone degeneration in ALS.
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Affiliation(s)
- Sandra Amor
- Department of Pathology, Amsterdam UMC Location VUmc, Amsterdam, the Netherlands.,Department of Neuroscience and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Erik Nutma
- Department of Pathology, Amsterdam UMC Location VUmc, Amsterdam, the Netherlands
| | - Manuel Marzin
- Department of Pathology, Amsterdam UMC Location VUmc, Amsterdam, the Netherlands
| | - Fabiola Puentes
- Department of Neuroscience and Trauma, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Fichtner ML, Jiang R, Bourke A, Nowak RJ, O'Connor KC. Autoimmune Pathology in Myasthenia Gravis Disease Subtypes Is Governed by Divergent Mechanisms of Immunopathology. Front Immunol 2020; 11:776. [PMID: 32547535 PMCID: PMC7274207 DOI: 10.3389/fimmu.2020.00776] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/06/2020] [Indexed: 12/13/2022] Open
Abstract
Myasthenia gravis (MG) is a prototypical autoantibody mediated disease. The autoantibodies in MG target structures within the neuromuscular junction (NMJ), thus affecting neuromuscular transmission. The major disease subtypes of autoimmune MG are defined by their antigenic target. The most common target of pathogenic autoantibodies in MG is the nicotinic acetylcholine receptor (AChR), followed by muscle-specific kinase (MuSK) and lipoprotein receptor-related protein 4 (LRP4). MG patients present with similar symptoms independent of the underlying subtype of disease, while the immunopathology is remarkably distinct. Here we highlight these distinct immune mechanisms that describe both the B cell- and autoantibody-mediated pathogenesis by comparing AChR and MuSK MG subtypes. In our discussion of the AChR subtype, we focus on the role of long-lived plasma cells in the production of pathogenic autoantibodies, the IgG1 subclass mediated pathology, and contributions of complement. The similarities underlying the immunopathology of AChR MG and neuromyelitis optica (NMO) are highlighted. In contrast, MuSK MG is caused by autoantibody production by short-lived plasmablasts. MuSK MG autoantibodies are mainly of the IgG4 subclass which can undergo Fab-arm exchange (FAE), a process unique to this subclass. In FAE IgG4, molecules can dissociate into two halves and recombine with other half IgG4 molecules resulting in bispecific antibodies. Similarities between MuSK MG and other IgG4-mediated autoimmune diseases, including pemphigus vulgaris (PV) and chronic inflammatory demyelinating polyneuropathy (CIDP), are highlighted. Finally, the immunological distinctions are emphasized through presentation of biological therapeutics that provide clinical benefit depending on the MG disease subtype.
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Affiliation(s)
- Miriam L Fichtner
- Department of Neurology, School of Medicine, Yale University, New Haven, CT, United States.,Department of Immunobiology, School of Medicine, Yale University, New Haven, CT, United States
| | - Ruoyi Jiang
- Department of Immunobiology, School of Medicine, Yale University, New Haven, CT, United States
| | - Aoibh Bourke
- Trinity Hall, University of Cambridge, Cambridge, United Kingdom
| | - Richard J Nowak
- Department of Neurology, School of Medicine, Yale University, New Haven, CT, United States
| | - Kevin C O'Connor
- Department of Neurology, School of Medicine, Yale University, New Haven, CT, United States.,Department of Immunobiology, School of Medicine, Yale University, New Haven, CT, United States
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Miyake Z, Ishii K, Matsuo H, Higuchi O, Tamaoka A. Isolated bilateral abducens paralysis without ptosis in an anti-LDL receptor-related protein 4 antibody-positive patient treated effectively with steroid-pulse therapy. J Neurol Sci 2018; 390:42-43. [PMID: 29801905 DOI: 10.1016/j.jns.2018.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 03/27/2018] [Accepted: 04/04/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Zenshi Miyake
- Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennnoudai, Tsukuba, Ibaraki 305-8575, Japan
| | - Kazuhiro Ishii
- Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennnoudai, Tsukuba, Ibaraki 305-8575, Japan.
| | - Hidenori Matsuo
- Department of Neurology, Nagasaki Kawatana Medical Center, 2005-1, Shimogumi-go, Kawatana-cho, Higashisonogi-gun, Nagasaki 859-3615, Japan
| | - Osamu Higuchi
- Department of Clinical Research, Nagasaki Kawatana Medical Center, 2005-1, Shimogumi-go, Kawatana-cho, Higashisonogi-gun, Nagasaki 859-3615, Japan
| | - Akira Tamaoka
- Department of Neurology, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennnoudai, Tsukuba, Ibaraki 305-8575, Japan
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Abstract
PURPOSE OF REVIEW Myasthenia gravis, a rare disorder of the neuromuscular transmission, is increasingly acknowledged as a syndrome more than as a single disease. This review summarizes recent advances in pathophysiology which confirm the disease heterogeneity, and may help find disease-targeted and patient-targeted therapies. RECENT FINDINGS Antibodies to the acetylcholine receptor, the muscle-specific tyrosine kinase and the lipoprotein receptor protein 4, characterize disease subtypes with distinct clinical traits and immune-pathogenic mechanisms. Genome-wide approaches have identified susceptibility loci within genes that participate in the immune response. Regulatory T and B cells appear to be defective in myasthenia gravis. In patients with acetylcholine receptor antibodies, thymectomy associated with prednisone proved more effective than prednisone alone in a multicenter randomized trial. New therapeutic options target B cells, B-cell growth factors and complement inhibition, and are currently reserved for patients with refractory disease. SUMMARY In the recent past, there has been an active search for new antigens in myasthenia gravis, whereas clinical and experimental studies have provided new insights of crucial pathways in immune regulation, which might become the targets of future therapeutic interventions.
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Affiliation(s)
- Amelia Evoli
- Institute of Neurology, Catholic University, Fondazione Policlinico Gemelli, Roma, Italy
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Huang J, Zhang T, Wang H, Zhao Y. Treatment of experimental autoimmune myasthenia gravis rats with FTY720 and its effect on Th1/Th2 cells. Mol Med Rep 2018; 17:7409-7414. [PMID: 29568889 DOI: 10.3892/mmr.2018.8768] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 11/15/2017] [Indexed: 11/05/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neurological disease that is characterized by the expression of anti-acetylcholine receptor (AChR) antibodies. The immune response at AChRs of neuromuscular junction is disrupted in patients with MG, which manifests as skeletal muscle fatigue and is aggravated following periods of activity and alleviated following rest. Although a novel immune suppressant FTY720 drug, which exhibits strong immune suppression efficacy and minor adverse effects, is available, its role and mechanism in MG have not been elucidated. The aim of this study was to investigate the role of FTY720 in MG. A total of 60 healthy female Lewis rats were randomly assigned into 4 groups: Control group, Model group of experimental autoimmune myasthenia gravis (EAMG), 0.5 mg/kg FTY720-treatment EAMG group and 1.0 mg/kg FTY720‑treatment EAMG group. Body weight and symptoms were examined; Lennon score was used to evaluate improvement of clinical symptoms. Reverse transcription‑quantitative polymerase chain reaction and ELISA were used to test the mRNA and protein expression levels, respectively, of the helper T (Th)1 and Th2 cell cytokines, including interleukin (IL)‑2, interferon (IFN)‑γ, IL‑4 and IL‑6 in thymus tissue and serum. FTY720 treatment improved rat MG symptoms, increased body weight and decreased Lennon score. FTY720 treatments also reduced tissue and serum levels of IL‑2, IFN‑γ and IL‑6, but not IL‑4 expression levels. FTY720 suppressed the inflammatory response and improved EAMG symptoms by inhibiting the secretion of inflammatory factors.
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Affiliation(s)
- Jiankang Huang
- Department of Neurology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, P.R. China
| | - Ting Zhang
- Department of Neurology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, P.R. China
| | - Hongmei Wang
- Department of Neurology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, P.R. China
| | - Yuwu Zhao
- Department of Neurology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, P.R. China
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Ohnari K, Okada K, Higuchi O, Matsuo H, Adachi H. Late-onset Myasthenia Gravis Accompanied by Amyotrophic Lateral Sclerosis with Antibodies against the Acetylcholine Receptor and Low-density Lipoprotein Receptor-related Protein 4. Intern Med 2018; 57:3021-3024. [PMID: 30318496 PMCID: PMC6232022 DOI: 10.2169/internalmedicine.0966-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
An 82-year-old woman developed neck weakness and dysarthria with antibodies against acetylcholine receptor (AChR) and low-density lipoprotein receptor-related protein 4 (LRP4). Myasthenia gravis (MG) was diagnosed by edrophonium and repetitive nerve stimulation tests. Her symptoms resolved completely by immunotherapy. One year later, she presented with muscle weakness and bulbar palsy accompanied by atrophy and fasciculation. Her tendon reflexes were brisk, and Babinski's sign was positive. She was diagnosed with probable amyotrophic lateral sclerosis (ALS). Immunotherapy did not improve her symptoms, and she ultimately died of respiratory failure. MG and ALS may share a pathophysiology, including anti-LRP4 antibodies at the neuromuscular junction.
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Affiliation(s)
- Keiko Ohnari
- Department of Neurology, University of Occupational and Environmental Health School of Medicine, Japan
| | - Kazumasa Okada
- Department of Neurology, University of Occupational and Environmental Health School of Medicine, Japan
| | - Osamu Higuchi
- Department of Clinical Research, National Hospital Organization Nagasaki Kawatana Medical Center, Japan
| | - Hidenori Matsuo
- Department of Neurology, National Hospital Organization Nagasaki Kawatana Medical Center, Japan
| | - Hiroaki Adachi
- Department of Neurology, University of Occupational and Environmental Health School of Medicine, Japan
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Autoantibodies to Low-Density Lipoprotein Receptor-Related Protein 4 in Double Seronegative Myasthenia Gravis: A Systematic Review. Can J Neurol Sci 2017; 45:62-67. [DOI: 10.1017/cjn.2017.253] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AbstractBackground: Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction in which a clinical diagnosis may be confirmed with serological testing. The most common autoantibodies used to support a diagnosis of MG are anti-acetylcholine receptor antibodies and anti-muscle-specific tyrosine kinase antibodies. In cases in which both of these autoantibodies are negative (termed double-seronegative [dSNMG]), other autoantibodies such as low-density lipoprotein receptor-related protein 4 (LRP4) may be used to aid in diagnosis. Methods: We have undertaken a systematic literature review to identify studies that have assessed the frequency of anti-LRP4 antibodies in dSNMG patients and the characteristics of anti-LRP4+ dSNMG patients (epidemiology, clinical features, electromyographic findings, or management). PubMed, EMBASE, Medline, and Scopus were searched on January 14, 2017, using the medical subject headings “myasthenia gravis” and “low-density lipoprotein receptor-related protein 4” or “LRP4.” Results: The initial search identified 367 articles. Fourteen publications met the inclusion criteria. There were ten cross-sectional research studies, three were case series, and one was a case report. The majority of studies were limited by small sample sizes of LRP4+ dSNMG. There has been a wide range of frequencies of anti-LRP4 antibodies detected in different MG patient populations, some involving different laboratory techniques. Conclusions: LRP4+ dSNMG is more likely than LRP4– dSNMG to have a younger onset of disease and occur in females. LRP4+ dSNMG most often is mild in severity and often involves isolated ocular weakness. It typically responds well to pyridostigmine or prednisone.
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Tai H, Cui L, Guan Y, Liu M, Li X, Huang Y, Yuan J, Shen D, Li D, Zhai F. Amyotrophic Lateral Sclerosis and Myasthenia Gravis Overlap Syndrome: A Review of Two Cases and the Associated Literature. Front Neurol 2017; 8:218. [PMID: 28588549 PMCID: PMC5439131 DOI: 10.3389/fneur.2017.00218] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 05/04/2017] [Indexed: 01/21/2023] Open
Abstract
Objective To describe the characteristics of patients with amyotrophic lateral sclerosis (ALS) and myasthenia gravis (MG) overlap syndrome and explore the relationship between the two diseases. Methods We conducted a search of medical records at Peking Union Medical University Hospital from 1983 to 2015 for coexistence of ALS and MG and searched the PubMed database for all literature describing ALS and MG overlap syndrome published through December 2016. We analyzed the clinical and neurophysiological characteristics of patients by groups according to strict diagnostic criteria. Results We presented 2 patients in our database with combined ALS and MG, and together with 25 cases reported in the literature, the patients were divided into 4 groups: 12 patients with MG followed by ALS, 8 patients with ALS followed by MG, 5 ALS patients with false-positive anti-acetylcholine receptor, and the other 2 ALS patients with only myasthenia symptoms. Most patients had limb onset ALS, and myasthenia symptoms mainly affected ocular and bulbar muscles. Clinical and neurophysiological characteristics were summarized. Conclusion These findings support the conclusion that immunological mechanisms and alterations in the neuromuscular junction are related to ALS pathogenesis.
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Affiliation(s)
- Hongfei Tai
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Liying Cui
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Neuroscience Center, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuzhou Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Mingsheng Liu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoguang Li
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Huang
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Yuan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Dongchao Shen
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Dawei Li
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Feifei Zhai
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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