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da Silva LNM, Filho AGO, Guimarães JB. Authors' response to the Letter to the Editor. Skeletal Radiol 2024; 53:2287. [PMID: 38319383 DOI: 10.1007/s00256-024-04608-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Affiliation(s)
- Lucas N M da Silva
- Department of Musculoskeletal Radiology, Fleury Medicina E Saúde, Sao Paulo, Brazil
| | | | - Júlio Brandão Guimarães
- Department of Musculoskeletal Radiology, Fleury Medicina E Saúde, Sao Paulo, Brazil.
- Department of Radiology, Universidade Federal de Sao Paulo, UNIFESP-EPM, Sao Paulo, Brazil.
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, USA.
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2
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Li HN, Xu XN, Qin YH, Liu R, Guo WY, Huang XY, Fan ML, Zhang LJ, Qi Y, Zhang C, Yang L, Shi FD, Yang CS. Clinical features of COVID-19 infection in patients with myasthenia gravis: a real-world retrospective study. Front Public Health 2024; 12:1421211. [PMID: 39257951 PMCID: PMC11384569 DOI: 10.3389/fpubh.2024.1421211] [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: 05/10/2024] [Accepted: 08/13/2024] [Indexed: 09/12/2024] Open
Abstract
Objective We investigated the risk factors associated with severe or critical Coronavirus disease 2019 (COVID-19) infection due to the Omicron variant in patients with myasthenia gravis (MG) and determined the potential effect of COVID-19 on myasthenic exacerbation during the Omicron pandemic. Methods This retrospective study included 287 patients with MG in Tianjin, China. Clinical data of the patients were collected using electronic questionnaires, databases, and clinical records. Results The overall infection rate was 84.7%. Advanced age, comorbidities, generalized phenotype, and MG instability were drivers of COVID-19 severity, and post-COVID-19 myasthenic exacerbation. The concurrent use of a steroid-sparing agent did not affect COVID-19 susceptibility or severity. It did lower the risk of myasthenic exacerbation after COVID-19 infection. Patients with severe COVID-19 experienced myasthenic exacerbation earlier than patients with non-severe infection (p < 0.001). The severity of COVID-19 (Hazards Ratio = 3.04, 95% CI: 1.41-6.54, p = 0.004) and the clinical phenotype (Hazards Ratio = 3.29, 95% CI: 1.63-6.63, p < 0.001) emerged as independent risk factors for early MG exacerbation. Conclusion Generally, patients with MG appear to be susceptible to the Omicron strains. Immunotherapy for MG did not increase COVID-19 susceptibility or severity. We do not advocate an immediate cessation of ongoing immunosuppressive treatments once a COVID-19 infection is diagnosed. Instead, a judicious evaluation of the risks and benefits, tailored to each individual, is recommended.
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Affiliation(s)
- Hui-Ning Li
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiao-Na Xu
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Ying-Hui Qin
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Rui Liu
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Wen-Yue Guo
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiao-Yu Huang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Mo-Li Fan
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Lin-Jie Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuan Qi
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Chao Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Yang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fu-Dong Shi
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chun-Sheng Yang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Li J, Zheng Y, Zhao Y, Qi K, Lin G, Liu R, Hao H, Wang Z, Yuan Y, Gao F. COVID-19 in patients with myasthenia gravis: a single-center retrospective study in China. Neurol Sci 2024; 45:2969-2976. [PMID: 38652194 DOI: 10.1007/s10072-024-07518-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 04/02/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has been a great concern since 2019. Patients with myasthenia gravis (MG) may be at higher risk of COVID-19 and a more severe disease course. We examined the associations between COVID-19 and MG. METHODS This single-center retrospective cohort study involved 134 patients who were diagnosed with MG from June 2020 to November 2022 and followed up until April 2023. They were divided into a COVID-19 group and non-COVID-19 group. Logistic regression analysis was used to detect factors potentially associating COVID-19 with MG. RESULTS Of the 134 patients with MG, 108 (80.6%) had COVID-19. A higher number of comorbidities was significantly associated with an increased risk of COVID-19 (p = 0.040). A total of 103 patients (95.4%) had mild/moderate COVID-19 symptoms, and 4 patients (3.7%) were severe/critical symptoms (including 2 deaths). Higher age (p = 0.036), use of rituximab (p = 0.037), tumors other than thymoma (p = 0.031), Hashimoto's thyroiditis (p = 0.011), more comorbidities (p = 0.002), and a higher baseline MG activities of daily living (MG-ADL) score (p = 0.006) were risk factors for severe COVID-19 symptoms. The MG-ADL score increased by ≥ 2 points in 16 (15.7%) patients. Dry cough and/or expectoration (p = 0.011), use of oral corticosteroids (p = 0.033), and use of more than one kind of immunosuppressant (p = 0.017) were associated with the increase of the post-COVID-19 MG-ADL score. CONCLUSION Most patients with MG have a mild course of COVID-19. However, patients with older age, many comorbidities, a high MG-ADL score, and use of a variety of immunosuppressants during COVID-19 may be more prone to severe symptoms.
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Affiliation(s)
- Jiayi Li
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Yiming Zheng
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Yawen Zhao
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Kang Qi
- Department of Thoracic Surgery, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Gang Lin
- Department of Thoracic Surgery, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Ran Liu
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Hongjun Hao
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Zhaoxia Wang
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Yun Yuan
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Feng Gao
- Neurology Department, Peking University First Hospital, No.8 Xishiku Street, Xicheng District, Beijing, 100034, China.
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Jha S, Pendyala SK. MuSK Antibody-Positive Myasthenia Gravis With SARS CoV-2 Infection: A Case Report and Literature Review. J Clin Neuromuscul Dis 2024; 25:203-205. [PMID: 38771234 DOI: 10.1097/cnd.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Affiliation(s)
- Shreyashi Jha
- Department of Neurology, Institute of Neurosciences Kolkata, West Bengal, India
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Cheyne I, Gopinath VS, Muppa N, Armas AE, Gil Agurto MS, Akula SA, Nagpal S, Yousaf MS, Haider A. The Neurological Implications of COVID-19: A Comprehensive Narrative Review. Cureus 2024; 16:e60376. [PMID: 38887342 PMCID: PMC11181960 DOI: 10.7759/cureus.60376] [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: 05/15/2024] [Indexed: 06/20/2024] Open
Abstract
The COVID-19 pandemic caused by the coronavirus SARS-CoV-2 revealed a huge number of problems as well as discoveries in medicine, notably, regarding the effects of the virus on the central nervous system (CNS) and peripheral nervous system (PNS). This paper is a narrative review that takes a deep dive into the complex interactions between COVID-19 and the NS. Therefore, this paper explains the broad range of neurological manifestations and neurodegenerative diseases caused by the virus. It carefully considers the routes through which SARS-CoV-2 reaches the NS, including the olfactory system and of course, the hematogenous route, which are also covered when discussing the virus's direct and indirect mechanisms of neuropathogenesis. Besides neurological pathologies such as stroke, encephalitis, Guillain-Barré syndrome, Parkinson's disease, and multiple sclerosis, the focus area is also given to the challenges of making diagnosis, treatment, and management of these conditions during the pandemic. The review also examines the strategic and interventional approaches utilized to prevent these disorders, as well as the ACE2 receptors implicated in the mediation of neurological effects caused by COVID-19. This detailed overview, which combines research outputs with case data, is directed at tackling this pandemic challenge, with a view toward better patient care and outcomes in the future.
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Affiliation(s)
- Ithamar Cheyne
- Critical Care, Medical University of Warsaw, Warsaw, POL
| | | | - Neeharika Muppa
- School of Medicine, St. George's University, St. George's, GRD
| | - Angel Emanuel Armas
- Internal Medicine, Cardiac Arrhythmia Service, Harvard Medical School, Boston, USA
| | | | - Sai Abhigna Akula
- Internal Medicine, School of Medicine, St. George's University, St. George's, GRD
| | - Shubhangi Nagpal
- Internal Medicine, Guru Gobind Singh Government Hospital, New Delhi, IND
| | | | - Ali Haider
- Allied Health Sciences, The University of Lahore, Gujrat Campus, Gujrat, PAK
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Huang S, Wang Y, Zhu J, Li S, Lin S, Xie W, Chen S, Wang Y, Wang L, Jin Q, Weng Y, Yang D. Systemic Inflammatory Response Index, a Potential Inflammatory Biomarker in Disease Severity of Myasthenia Gravis: A Pilot Retrospective Study. J Inflamm Res 2024; 17:2563-2574. [PMID: 38686359 PMCID: PMC11057634 DOI: 10.2147/jir.s449324] [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: 11/10/2023] [Accepted: 03/26/2024] [Indexed: 05/02/2024] Open
Abstract
Purpose Myasthenia gravis (MG) is a chronic autoimmune disease caused by neuromuscular junction (NMJ) dysfunction. Our current understanding of MG's inflammatory component remains poor. The systemic inflammatory response index (SIRI) presents a promising yet unexplored biomarker for assessing MG severity. This study aimed to investigate the potential relationship between SIRI and MG disease severity. Patients and Methods We conducted a retrospective analysis of clinical data from 171 MG patients admitted between January 2016 and June 2021. Patients with incomplete data, other autoimmune diseases, or comorbidities were excluded. Disease severity was evaluated using the Myasthenia Gravis Foundation of America (MGFA) classification and Myasthenia Gravis Activities of Daily Living (MG-ADL) on admission. The association between SIRI and disease severity was assessed through logistic regression analysis, along with receiver operating characteristic (ROC) curve and decision curve analysis (DCA) comparisons with established inflammation indicators. Results After exclusion, 143 patients were analyzed in our study. SIRI levels significantly differed between patients with higher and lower disease severity (p < 0.001). Univariate logistic regression showed that SIRI had a significant effect on high disease severity (OR = 1.376, 95% CI 1.138-1.664, p = 0.001). This association remained significant even after adjusting for age, sex, disease duration, history of MG medication and thymoma (OR = 1.308, 95% CI 1.072-1.597, p = 0.008). Additionally, a positive correlation between SIRI and MG-ADL was observed (r = 0.232, p = 0.008). Significant interactions were observed between SIRI and immunosuppressor (p interaction = 0.001) and intravenous immunoglobulin (p interaction = 0.005). DCA demonstrated the superior net clinical benefit of SIRI compared to other markers when the threshold probability was around 0.2. Conclusion Our findings indicate a strong independent association between SIRI and disease severity in MG, suggesting SIRI's potential as a valuable biomarker for MG with superior clinical benefit to currently utilized markers.
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Affiliation(s)
- Suwen Huang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Yanchu Wang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First School of Medicine, School of Information and Engineering, Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Jinrong Zhu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Shengqi Li
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First School of Medicine, School of Information and Engineering, Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Shenyi Lin
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First School of Medicine, School of Information and Engineering, Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Wei Xie
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First School of Medicine, School of Information and Engineering, Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Siyao Chen
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First School of Medicine, School of Information and Engineering, Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Yukai Wang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Lingsheng Wang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First School of Medicine, School of Information and Engineering, Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Qiaoqiao Jin
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First School of Medicine, School of Information and Engineering, Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Yiyun Weng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Dehao Yang
- Department of Neurology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
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Skok M. The role of α7 nicotinic acetylcholine receptors in post-acute sequelae of covid-19. Int J Biochem Cell Biol 2024; 168:106519. [PMID: 38218363 DOI: 10.1016/j.biocel.2024.106519] [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: 11/24/2023] [Revised: 12/25/2023] [Accepted: 01/08/2024] [Indexed: 01/15/2024]
Abstract
Post-Acute Sequelae of COVID-19 or Long COVID becomes evident some weeks to months following acute COVID-19. Symptoms include cognitive impairment and varying degrees of memory loss with no definitive etiologies or efficacious therapies forthcoming even after four years of the SARS-Cov2 pandemic virus. The aim of this review is to demonstrate the important role of α7 nicotinic acetylcholine receptors in both acute COVID-19 and Long COVID. Evidence presented implicates immune mechanisms stimulated by SARS-Cov-2 S-protein fragment 674-685 that possesses homology with α7-specific ligands. Cognitive dysfunctions observed in Long COVID patients may be derived from anti-idiotypic α7-specific antibodies stimulated by (674-685)-specific antibodies. Therapeutic interventions capable of neutralizing these antibodies and restoring full functions of α7 nicotinic acetylcholine receptors appear to be of paramount importance in post-acute sequelae of COVID-19.
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Affiliation(s)
- Maryna Skok
- Palladin Institute of Biochemistry, 9, Leontovycha str, 01054 Kyiv, Ukraine.
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8
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Habib AA, Sacks N, Cool C, Durgapal S, Dennen S, Everson K, Hughes T, Hernandez J, Phillips G. Hospitalizations and Mortality From Myasthenia Gravis: Trends From 2 US National Datasets. Neurology 2024; 102:e207863. [PMID: 38165317 DOI: 10.1212/wnl.0000000000207863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 10/03/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Myasthenia gravis (MG) is a rare neuromuscular disorder where IgG antibodies damage the communication between nerves and muscles, leading to muscle weakness that can be severe and have a significant impact on patients' lives. MG exacerbations include myasthenic crisis with respiratory failure, the most serious manifestation of MG. Recent studies have found MG prevalence increasing, especially in older patients. This study examined trends in hospital admissions and in-hospital mortality for adult patients with MG and readmissions and postdischarge mortality in older (65 years or older) adults with MG. METHODS Data from the Nationwide Inpatient Sample (NIS), an all-payer national database of hospital discharges, were used to characterize trends in hospitalizations and in-hospital mortality related to MG exacerbations and MG crisis among adult patients aged 18 years or older. The Medicare Limited Data Set, a deidentified, longitudinal research database with demographic, enrollment, and claims data was used to assess hospitalizations, length of stay (LOS), readmissions, and 30-day postdischarge mortality among fee-for-service Medicare beneficiaries aged 65 years or older. The study period was 2010-2019. Multinomial logit models and Poisson regression were used to test for significance of trends. RESULTS Hospitalization rates for 19,715 unique adult patients and 56,822 admissions increased from 2010 to 2019 at an average annualized rate of 4.9% (MG noncrisis: 4.4%; MG crisis: 6.8%; all p < 0.001). Readmission rates were approximately 20% in each study year for both crisis and noncrisis hospitalizations; the in-hospital mortality rate averaged 1.8%. Among patients aged 65 years or older, annualized increases in hospitalizations were estimated at 5.2%, 4.2%, and 7.7% for all, noncrisis, and crisis hospitalizations, respectively (all p < 0.001). The average LOS was stable over the study period, ranging from 11.3 to 13.1 days, but was consistently longer for MG crisis admissions. Mortality among patients aged 65 years or older was higher compared with that in all patients, averaging 5.0% across each of the study years. DISCUSSION Increasing hospitalization rates suggest a growing burden associated with MG, especially among older adults. While readmission and mortality rates have remained stable, the increasing hospitalization rates indicate that the raw numbers of readmissions-and deaths-are also increasing. Mortality rates are considerably higher in older patients hospitalized with MG.
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Affiliation(s)
- Ali A Habib
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Naomi Sacks
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Christina Cool
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Sneha Durgapal
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Syvart Dennen
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Katie Everson
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Tom Hughes
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Jennifer Hernandez
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Glenn Phillips
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
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Curran CS, Cui X, Li Y, Jeakle M, Sun J, Demirkale CY, Minkove S, Hoffmann V, Dhamapurkar R, Chumbris S, Bolyard C, Iheanacho A, Eichacker PQ, Torabi-Parizi P. Anti-PD-L1 therapy altered inflammation but not survival in a lethal murine hepatitis virus-1 pneumonia model. Front Immunol 2024; 14:1308358. [PMID: 38259435 PMCID: PMC10801642 DOI: 10.3389/fimmu.2023.1308358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/05/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Because prior immune checkpoint inhibitor (ICI) therapy in cancer patients presenting with COVID-19 may affect outcomes, we investigated the beta-coronavirus, murine hepatitis virus (MHV)-1, in a lethal pneumonia model in the absence (Study 1) or presence of prior programmed cell death ligand-1 (PD-L1) antibody (PD-L1mAb) treatment (Study 2). Methods In Study 1, animals were inoculated intratracheally with MHV-1 or vehicle and evaluated at day 2, 5, and 10 after infection. In Study 2, uninfected or MHV-1-infected animals were pretreated intraperitoneally with control or PD-L1-blocking antibodies (PD-L1mAb) and evaluated at day 2 and 5 after infection. Each study examined survival, physiologic and histologic parameters, viral titers, lung immunophenotypes, and mediator production. Results Study 1 results recapitulated the pathogenesis of COVID-19 and revealed increased cell surface expression of checkpoint molecules (PD-L1, PD-1), higher expression of the immune activation marker angiotensin converting enzyme (ACE), but reduced detection of the MHV-1 receptor CD66a on immune cells in the lung, liver, and spleen. In addition to reduced detection of PD-L1 on all immune cells assayed, PD-L1 blockade was associated with increased cell surface expression of PD-1 and ACE, decreased cell surface detection of CD66a, and improved oxygen saturation despite reduced blood glucose levels and increased signs of tissue hypoxia. In the lung, PD-L1mAb promoted S100A9 but inhibited ACE2 production concomitantly with pAKT activation and reduced FOXO1 levels. PD-L1mAb promoted interferon-γ but inhibited IL-5 and granulocyte-macrophage colony-stimulating factor (GM-CSF) production, contributing to reduced bronchoalveolar lavage levels of eosinophils and neutrophils. In the liver, PD-L1mAb increased viral clearance in association with increased macrophage and lymphocyte recruitment and liver injury. PD-L1mAb increased the production of virally induced mediators of injury, angiogenesis, and neuronal activity that may play role in COVID-19 and ICI-related neurotoxicity. PD-L1mAb did not affect survival in this murine model. Discussion In Study 1 and Study 2, ACE was upregulated and CD66a and ACE2 were downregulated by either MHV-1 or PD-L1mAb. CD66a is not only the MHV-1 receptor but also an identified immune checkpoint and a negative regulator of ACE. Crosstalk between CD66a and PD-L1 or ACE/ACE2 may provide insight into ICI therapies. These networks may also play role in the increased production of S100A9 and neurological mediators in response to MHV-1 and/or PD-L1mAb, which warrant further study. Overall, these findings support observational data suggesting that prior ICI treatment does not alter survival in patients presenting with COVID-19.
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Affiliation(s)
- Colleen S. Curran
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Yan Li
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Mark Jeakle
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Cumhur Y. Demirkale
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Samuel Minkove
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Victoria Hoffmann
- Division of Veterinary Resources, National Institutes of Health, Bethesda, MD, United States
| | - Rhea Dhamapurkar
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Symya Chumbris
- Texcell North-America, Inc., Frederick, MD, United States
| | | | | | - Peter Q. Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Parizad Torabi-Parizi
- National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, United States
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
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Antonioni A, Raho EM, Carlucci D, Sette E, De Gennaro R, Capone JG, Govoni V, Casetta I, Pugliatti M, Granieri E. The Incidence of Myasthenia Gravis in the Province of Ferrara, Italy, in the Period of 2008-2022: An Update on a 40-Year Observation and the Influence of the COVID-19 Pandemic. J Clin Med 2023; 13:236. [PMID: 38202243 PMCID: PMC10780173 DOI: 10.3390/jcm13010236] [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: 12/06/2023] [Revised: 12/23/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Myasthenia gravis (MG) is the most common neuromuscular junction disorder. We evaluated the MG incidence rate in the province of Ferrara, Northern Italy, over two time frames (2008-2018 and 2019-2022, i.e., the COVID-19 pandemic) and considered early-onset (EOMG), late-onset (LOMG), and thymoma- and non-thymoma-associated MG. Moreover, in the second period, we assessed its possible relationship with SARS-CoV-2 infection or COVID-19 vaccination. We used a complete enumeration approach to estimate the MG incidence and its temporal trend. For the period of 2008-18, 106 new cases were identified (mean incidence rate 2.7/100,000 people). The highest rates were observed for the over-70 age group and in rural areas, with 17% of thymoma-associated MG. During the COVID-19 period, 29 new cases were identified (average incidence rate 2.1/100,000 people), showing a marked (though not statistically significant) decrease in the mean annual incidence compared to the previous period. Again, the highest rate was observed for the over-70 age group. The first period was in line with our previous observations for the period between 1985 and 2007, highlighting a rising incidence of LOMG and a marked decrease in EOMG. During the COVID-19 period, incidence rates were lower in the first years whereas, when the pandemic ended, the previous trend was confirmed.
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Affiliation(s)
- Annibale Antonioni
- Unit of Neurology, Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.A.); (E.M.R.); (I.C.); (M.P.)
- Doctoral Program in Translational Neurosciences and Neurotechnologies, Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy
| | - Emanuela Maria Raho
- Unit of Neurology, Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.A.); (E.M.R.); (I.C.); (M.P.)
| | - Domenico Carlucci
- Unit of Neurology, Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.A.); (E.M.R.); (I.C.); (M.P.)
| | - Elisabetta Sette
- Unit of Neurology, Interdistrict Health Care Department of Neurosciences, S. Anna Ferrara University Hospital, 44124 Ferrara, Italy
| | - Riccardo De Gennaro
- Unit of Neurology, Interdistrict Health Care Department of Neurosciences, S. Anna Ferrara University Hospital, 44124 Ferrara, Italy
| | - Jay Guido Capone
- Unit of Neurology, Interdistrict Health Care Department of Neurosciences, S. Anna Ferrara University Hospital, 44124 Ferrara, Italy
| | - Vittorio Govoni
- Unit of Neurology, Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.A.); (E.M.R.); (I.C.); (M.P.)
| | - Ilaria Casetta
- Unit of Neurology, Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.A.); (E.M.R.); (I.C.); (M.P.)
| | - Maura Pugliatti
- Unit of Neurology, Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.A.); (E.M.R.); (I.C.); (M.P.)
| | - Enrico Granieri
- Unit of Neurology, Department of Neurosciences and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (A.A.); (E.M.R.); (I.C.); (M.P.)
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11
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Arbel A, Bishara H, Barnett-Griness O, Cohen S, Najjar-Debbiny R, Gronich N, Auriel E, Saliba W. Association between COVID-19 vaccination and myasthenia gravis: A population-based, nested case-control study. Eur J Neurol 2023; 30:3868-3876. [PMID: 37552795 DOI: 10.1111/ene.16025] [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: 03/30/2023] [Revised: 07/09/2023] [Accepted: 07/30/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Existing data regarding the link between COVID-19 vaccine and myasthenia gravis (MG) are scarce. We aimed to assess the association between Pfizer-BioNTech vaccine with both new-onset MG and MG exacerbation. METHODS For the first aim, we conducted a nested case-control study in a cohort of 3,052,467 adults, without a diagnosis of MG, from the largest healthcare provider in Israel. Subjects were followed from January 1, 2021 until June 30, 2022 for the occurrence of MG. Ten randomly selected controls were matched to each case of new-onset MG on age and sex. For the second aim, a nested case-control study was conducted in a cohort of 1446 MG patients. Four randomly selected MG patients (controls) were matched to each case of MG exacerbation. Exposure to COVID-19 vaccine in the prior 4 weeks was assessed in cases and controls. RESULTS Overall, 332 patients had new-onset MG and were matched with 3320 controls. Multivariable conditional logistic regression models showed that the odds ratio (OR) for new-onset MG, associated with COVID-19 vaccine, was 1.14 (95% CI 0.73-1.78). The results were consistent in sensitivity analysis that used more stringent criteria to define MG. Overall, 62 patients with MG exacerbation were matched to 248 MG controls. The multivariable OR for MG exacerbation, associated with COVID-19 vaccine, was 1.35 (95% CI 0.37-4.89). All results were similar when the prior exposure to COVID-19 vaccine was extended to 8 weeks. CONCLUSION This study suggests that Pfizer-BioNTech vaccine is not associated with increased risk of new-onset nor exacerbation of MG.
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Affiliation(s)
- Anat Arbel
- Department of Internal Medicine B, Lady Davis Carmel Medical Center, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Haya Bishara
- Department of Neurology, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Ofra Barnett-Griness
- Statistical Unit, Lady Davis Carmel Medical Center, Haifa, Israel
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Shai Cohen
- Department of Internal Medicine B, Lady Davis Carmel Medical Center, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ronza Najjar-Debbiny
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Infection Control and Prevention Unit, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Naomi Gronich
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Eitan Auriel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Walid Saliba
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Haifa, Israel
- Translational Epidemiology Unit and Research Authority, Lady Davis Carmel Medical Center, Haifa, Israel
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12
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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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13
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Zhong H, Huan X, Zhao R, Su M, Yan C, Song J, Xi J, Zhao C, Luo F, Luo S. Peripheral immune landscape for hypercytokinemia in myasthenic crisis utilizing single-cell transcriptomics. J Transl Med 2023; 21:564. [PMID: 37620910 PMCID: PMC10464341 DOI: 10.1186/s12967-023-04421-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is the most prevalent autoimmune disorder affecting the neuromuscular junction. A rapid deterioration in respiratory muscle can lead to a myasthenic crisis (MC), which represents a life-threatening condition with high mortality in MG. Multiple CD4+ T subsets and hypercytokinemia have been identified in the peripheral pro-inflammatory milieu during the crisis. However, the pathogenesis is complicated due to the many types of cells involved, leaving the underlying mechanism largely unexplored. METHODS We conducted single-cell transcriptomic and immune repertoire sequencing on 33,577 peripheral blood mononuclear cells (PBMCs) from two acetylcholine receptor antibody-positive (AChR +) MG patients during MC and again three months post-MC. We followed the Scanpy workflow for quality control, dimension reduction, and clustering of the single-cell data. Subsequently, we annotated high-resolution cell types utilizing transfer-learning models derived from publicly available single-cell immune datasets. RNA velocity calculations from unspliced and spliced mRNAs were applied to infer cellular state progression. We analyzed cell communication and MG-relevant cytokines and chemokines to identify potential inflammation initiators. RESULTS We identified a unique subset of monocytes, termed monocytes 3 (FCGR3B+ monocytes), which exhibited significant differential expression of pro-inflammatory signaling pathways during and after the crisis. In line with the activated innate immune state indicated by MC, a high neutrophil-lymphocyte ratio (NLR) was confirmed in an additional 22 AChR + MC patients in subsequent hemogram analysis and was associated with MG-relevant clinical scores. Furthermore, oligoclonal expansions were identified in age-associated B cells exhibiting high autoimmune activity, and in CD4+ and CD8+ T cells demonstrating persistent T exhaustion. CONCLUSIONS In summary, our integrated analysis of single-cell transcriptomics and TCR/BCR sequencing has underscored the role of innate immune activation which is associated with hypercytokinemia in MC. The identification of a specific monocyte cluster that dominates the peripheral immune profile may provide some hints into the etiology and pathology of MC. However, future functional studies are required to explore causality.
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Affiliation(s)
- Huahua Zhong
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Xiao Huan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Rui Zhao
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Manqiqige Su
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Chong Yan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Jie Song
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Jianying Xi
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Chongbo Zhao
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Feifei Luo
- Department of Digestive Diseases, Huashan Hospital, Fudan University, Shanghai, 200040, China.
| | - Sushan Luo
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China.
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14
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Yaman A, Kurtuluş Aydın F. Therapeutic and prognostic features in myasthenia gravis patients followed in a tertiary neuromuscular diseases center in Turkey. Front Neurol 2023; 14:1176636. [PMID: 37602241 PMCID: PMC10436092 DOI: 10.3389/fneur.2023.1176636] [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: 02/28/2023] [Accepted: 07/23/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction In this study, we aim to evaluate the treatment responses and prognostic characteristics of Myasthenia Gravis (MG) patients followed in a tertiary neuromuscular diseases center in Turkey. Methods One hundred seventy four MG patients (between years 2011 and 2022) in Antalya, Turkey were diagnosed, and evaluated on a classification of MG was based on Myasthenia. Gravis Foundation of America (MGFA) clinical classification. Exclusion of other possible diseases in the differential diagnosis and support by beneficial response to treatment with acetylcholinesterase inhibitors were also taken into consideration. Results Mean age of participants was 54.86 (SD = 14.856; min-max = 22-84). Ninety (51.7%) were female. MG was more common in women under the age of 65 (58%) and in men over the age of 65 (64%). Generalized MG was seen in 75.3% of the patients. Anti-AChR positivities were detected in 52.3%, Anti-MuSK positivity in 4.6%, and seronegativity in 22.4%. Thymoma was detected in nearly 9.8% and thymectomy was performed in 28.7 percent. Most of the patients (57.5%) were using corticosteroids. Azathioprine was used by 39% and mycophenolate mofetil by 10.3% of patients. Mortality was higher and disease was more severe in late-onset (>50 years) MG patients (especially in the COVID-19 pandemic). Eight patients (four women, four men, mean age 75.5 years) died during follow-up. None of them died due to myasthenic worsening, two died due to malignancy and two due to infection. During the COVID pandemic, 16 patients (9.2%) had COVID infection. Four patients died due to COVID-19 infection, these four patients had serious comorbidities, and three of them were elderly (>75 years). Conclusion In conclusion, MG is more common in women between the ages of 20-40 and in men over the age of 65. The use of corticosteroids was more common under the age of 50, and the use of non-steroidal immunosuppressant agents was more common over the age of 50. Thymectomy is still an important supportive treatment approach in anti-AChR positive and seronegative generalized patients under 50 years of age. IVIG and plasmapheresis are effective treatments during acute exacerbations and bridging periods of treatments. Specific treatments are needed especially for resistant group of patients.
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Affiliation(s)
- Aylin Yaman
- Neurology Department, Antalya Training and Research Hospital, Antalya, Türkiye
| | - Fatma Kurtuluş Aydın
- Neurology Department, Antalya Training and Research Hospital, Antalya, Türkiye
- Ankara Etlik City Hospital, Ankara, Türkiye
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15
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Croitoru CG, Cuciureanu DI, Hodorog DN, Grosu C, Cianga P. Autoimmune myasthenia gravis and COVID-19. A case report-based review. J Int Med Res 2023; 51:3000605231191025. [PMID: 37565671 PMCID: PMC10422912 DOI: 10.1177/03000605231191025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/13/2023] [Indexed: 08/12/2023] Open
Abstract
A potential relationship between COVID-19 infection and new onset myasthenia gravis (MG) has been suggested by the coexistence of these two diseases in a number of reports. This study aimed to assess their relationship by reviewing case studies of COVID-19 followed by new onset MG published between 01 December 2019 and 30 June 2023 identified by a search of PubMed/Medline database. In addition, we reviewed evidence in favour and against a potential cause and effect association, and described possible mechanisms that would underpin such a relationship. We identified 14 publications that reported 18 cases. Analysis showed the following features: age 19-83 years; 10 men/8 women; median time interval between COVID-19 and MG (17, 5-56 days); autoimmune comorbidities (4); generalised MG (14); ocular MG (4); thymoma (3); antiacetylcholine receptor antibody (16); antimuscle-specific kinase antibodies (2). All patients improved following treatment. Proof of direct causality between the two conditions can only be established in time by confirming epidemiological increase in the incidence of MG or elucidating pathogenic mechanisms to substantiate a possible cause-effect association, or both.
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Affiliation(s)
- Cristina Georgiana Croitoru
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
- Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, Iași, Romania
| | - Dan Iulian Cuciureanu
- Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, Iași, Romania
- Department Medical III, Department of Neurology,” Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Diana Nicoleta Hodorog
- Neurology Clinic, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, Iași, Romania
- Department Medical III, Department of Neurology,” Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Cristina Grosu
- Department Medical III, Department of Neurology,” Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Petru Cianga
- Department of Immunology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
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16
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Zhou S, Wen Y, Liu C, Zhong J, Liang M, Wu Y, Lv S, Gong Z, Lao D, Li T, Lu T, Tang J, Mo X, Huang W. Clinical Characteristics of Myasthenia Gravis Patients with COVID-19 in Guangxi, China: A Case-Control Study. J Inflamm Res 2023; 16:3157-3168. [PMID: 37525635 PMCID: PMC10387240 DOI: 10.2147/jir.s419307] [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: 04/29/2023] [Accepted: 07/08/2023] [Indexed: 08/02/2023] Open
Abstract
Purpose With the adjustment of prevention strategies in December 2022, coronavirus disease 2019 (COVID-19) became widely prevalent in China. This study is aimed to describe the clinical characteristics of myasthenia gravis (MG) patients with COVID-19 and identify risk factors of exacerbation in MG patients with COVID-19 in Guangxi. Patients and Methods A total of 489 MG patients and 587 control subjects in Guangxi during the COVID-19 pandemic were enrolled in this case-control study. After contacting the participants, the clinical data of MG patients and the control group were analyzed. The clinical characteristics of MG patients with COVID-19 were described. Multivariable logistic regression analysis was used for discovering independent risk factors of MG exacerbation in the patients with MG and COVID-19. Results A total of 311 (75.30%) MG patients and 428 (72.91%) control subjects were infected with COVID-19, and 64.31% of MG patients with COVID-19 were women. The median age at the time of interview was 41 (IQR: 28, 54) years old, and median onset age was 36 (IQR: 24, 51), both of which were lower than those in MG patients without COVID-19. MG duration was 24 (IQR: 9, 72) months. About 44.69% of patients were generalized MG (GMG). About 11.90% of MG patients with COVID-19 showed severe COVID-19 symptoms and the duration of symptomatic COVID-19 was 9.57 ± 6.79 days, higher than those in the control group. About 35.69% MG patients with immunosuppressive drugs were infected with COVID-19, which is higher than those in the non-infected MG patients (21.57%). A total of 120 (38.59%) MG patients with COVID-19 had comorbidities. About 21 (20.19%) of the 104 MG patients without vaccination showed severe COVID-19 symptoms. Multivariable logistic regression analysis showed that baseline MG activities of daily living profile (MG-ADL, OR 1.280, 95% CI: 1.010-1.621, p = 0.041), duration of COVID-19 (OR 1.158, 95% CI: 1.100-1.220, p < 0.001), GMG (OR 2.331, 95% CI: 1.228, 4.426, p = 0.010), and lack of COVID vaccination (OR 2.075, 95% CI: 1.152, 3.738, p = 0.015) were independent factors of exacerbation in MG patients with COVID-19. Conclusion MG patients with immunosuppressive drugs, younger onset, longer MG duration, or comorbidities are more susceptible to COVID-19. The baseline MG-ADL, duration of symptomatic COVID-19, GMG, and lack of COVID-19 vaccination are independent risk factors of exacerbation in MG patients with COVID-19.
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Affiliation(s)
- Shaodan Zhou
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Yishuang Wen
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Chao Liu
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Jian Zhong
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Manli Liang
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Yu Wu
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sirao Lv
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Zhuowei Gong
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Dayuan Lao
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Taiyan Li
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Ting Lu
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Jingqun Tang
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Xuean Mo
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
| | - Wen Huang
- Department of Neurology, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People’s Republic of China
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17
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Morgan L, Hollist M, Au K, Ayari L, Betts C, Kirmani BF. Neuromuscular Disorders Associated With COVID-19. Neurosci Insights 2023; 18:26331055231176251. [PMID: 37255741 PMCID: PMC10225906 DOI: 10.1177/26331055231176251] [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: 02/06/2023] [Accepted: 05/01/2023] [Indexed: 06/01/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has had an enormous impact on practically every aspect of daily life, and those with neuromuscular disorders have certainly not been spared. The effects of COVID-19 infection are far-reaching, going well beyond respiratory symptoms alone. From simple myalgias to debilitating critical illness neuromyopathies, we continue to learn and catalog the diverse pathologies presented by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as it relates to the neuromuscular system. Complications have been documented both as a direct result of primary infection but also in those with pre-existing neuromuscular disorders from myasthenia gravis to devastating critical illness neuromyopathies. In this review, we will discuss the relationship between COVID-19 infection and critical illness neuromyopathy, peripheral nerve palsies, myalgias, positional compressive neuropathy, myasthenia gravis, and Guillain-Barré syndrome.
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Affiliation(s)
| | | | | | - Lena Ayari
- Texas A&M University School of
Medicine, Bryan, TX, USA
| | - Colton Betts
- Texas A&M University School of
Medicine, Bryan, TX, USA
| | - Batool F Kirmani
- Texas A&M University School of
Medicine, Bryan, TX, USA
- Department of Neurology, CHI St. Joseph
Health, Bryan, TX, USA
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18
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Sehgal V, Kapila S, Taneja R, Mehmi P, Gulati N. Review of Neurological Manifestations of SARS-CoV-2. Cureus 2023; 15:e38194. [PMID: 37257164 PMCID: PMC10223874 DOI: 10.7759/cureus.38194] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 06/02/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can affect any part of the neuraxis. Many neurological conditions have been attributed to be caused by SARS-CoV-2, namely encephalopathy (acute necrotizing encephalopathy and encephalopathy with reversible splenial lesions), seizures, stroke, cranial nerve palsies, meningoencephalitis, acute disseminated encephalomyelitis (ADEM), transverse myelitis (long and short segment), Guillain-Barré syndrome (GBS) and its variants, polyneuritis cranialis, optic neuritis (ON), plexopathy, myasthenia gravis (MG), and myositis. The pathophysiology differs depending on the time frame of presentation. In patients with concomitant pulmonary disease, for instance, acute neurological illness appears to be caused by endotheliopathy and cytokine storm. Autoimmunity and molecular mimicry are causative for post-coronavirus disease 2019 (COVID-19)-sequelae. It has not yet been shown that the virus can penetrate the central nervous system (CNS) directly. This review aims to describe the disease and root pathogenic cause of the various neurological manifestations of COVID-19. We searched Pubmed/Medline and Google Scholar using the keywords "SARS-CoV-2" and "neurological illness" for articles published between January 2020 and November 2022. Then, we used the SWIFT-Review (Sciome LLC, North Carolina, United States), a text-mining workbench for systematic review, to classify the 1383 articles into MeSH hierarchical tree codes for articles on various parts of the nervous system, such as the CNS, peripheral nervous system, autonomic nervous system, neuromuscular junction, sensory system, and musculoskeletal system. Finally, we reviewed 152 articles in full text. SARS-CoV-2 RNA has been found in multiple brain areas without any histopathological changes. Despite the absence of in vivo virions or virus-infected cells, CNS inflammation has been reported, especially in the olfactory bulb and brain stem. SARS-CoV-2 genomes and proteins have been found in affected individuals' brain tissues, but corresponding neuropathologic changes are seldom found in these cases. Additionally, viral RNA can rarely be identified in neurological patients' CSF post hoc SARS-CoV-2 infection. Most patients with neurological symptoms do not have active viral replication in the nervous system and infrequently have typical clinical and laboratory characteristics of viral CNS infections. Endotheliopathy and the systemic inflammatory response to SARS-CoV-2 infection play a crucial role in developing neuro-COVID-19, with proinflammatory cytokine release mediating both pathological pathways. The systemic inflammatory mediators likely activate astrocytes and microglia across the blood-brain barrier, indirectly affecting CNS-specific immune activation and tissue injury. The management differs according to co-morbidities and the neurological disorder.
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Affiliation(s)
- Vineet Sehgal
- Neurology, Sehgal's Neuro & Child Care Center, Amritsar, IND
| | - Saniya Kapila
- General Practice, Fortis Escorts Hospital, Amritsar, IND
| | - Rishabh Taneja
- Medicine, Government Multi-Specialty Hospital, Chandigarh, IND
- Graduate Medical Education, Adesh Institute of Medical Sciences & Research, Bathinda, IND
| | - Prachi Mehmi
- Neurology, Adesh Institute of Medical Sciences & Research, Bathinda, IND
| | - Nihal Gulati
- General Practice, Navpreet Hospital, Amritsar, IND
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Virgilio E, Tondo G, Montabone C, Comi C. COVID-19 Vaccination and Late-Onset Myasthenia Gravis: A New Case Report and Review of the Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:ijerph20010467. [PMID: 36612789 PMCID: PMC9819717 DOI: 10.3390/ijerph20010467] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 05/20/2023]
Abstract
Myasthenia gravis (MG) is a rare autoimmune disease that is potentially threatening for patient life. Auto-antibodies targeting structures of the neuromuscular junction, particularly the acetylcholine receptor (AchR), are often found in the serum of MG patients. New-onset MG after SARS-CoV-2 vaccination has rarely been reported since the introduction of vaccination. Infections and COVID-19 infection have also been reported as possible triggers for a myasthenic crisis. We report a case of new-onset MG after receiving the mRNA COVID-19 vaccination. The patient was a 73-year-old male initially presenting with ocular symptoms and a rapid generalization. We also performed a literature revision of 26 described cases of MG after SARS-CoV-2 immunization. The patients were a majority of males with generalized late-onset MG occurring after the first dose of vaccine, similar to our patient. Only our patient showed a thymoma. Thymic mass and the positivity of AchR antibodies suggest that vaccination might have triggered a subclinical pre-existing MG with symptoms flaring. Clinicians should be aware of possible new-onset MG after COVID-19 vaccination, particularly in at-risk patients. Even though COVID-19 vaccination should be recommended in MG patients, particularly in well-compensated patients. However, more studies need to be performed in the future.
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Affiliation(s)
- Eleonora Virgilio
- Department of Translational Medicine, Section of Neurology, University of Eastern Piedmont, 28100 Novara, Italy
- Neurology Unit, Department of Translational Medicine, S. Andrea Hospital, University of Piemonte Orientale, 13100 Vercelli, Italy
| | - Giacomo Tondo
- Neurology Unit, Department of Translational Medicine, S. Andrea Hospital, University of Piemonte Orientale, 13100 Vercelli, Italy
| | - Claudia Montabone
- Neurology Unit, Department of Translational Medicine, S. Andrea Hospital, University of Piemonte Orientale, 13100 Vercelli, Italy
| | - Cristoforo Comi
- Neurology Unit, Department of Translational Medicine, S. Andrea Hospital, University of Piemonte Orientale, 13100 Vercelli, Italy
- Correspondence:
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