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Ingelfinger F, Kramer M, Lutz M, Widmer CC, Piccoli L, Kreutmair S, Wertheimer T, Woodhall M, Waters P, Sallusto F, Lanzavecchia A, Mundt S, Becher B, Schreiner B. Antibodies Produced by CLL Phenotype B Cells in Patients With Myasthenia Gravis Are Not Directed Against Neuromuscular Endplates. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/2/e200087. [PMID: 36754834 PMCID: PMC9909583 DOI: 10.1212/nxi.0000000000200087] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/28/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Myasthenia gravis (MG) can in rare cases be an autoimmune phenomenon associated with hematologic malignancies such as chronic lymphocytic leukemia (CLL). It is unclear whether in patients with MG and CLL, the leukemic B cells are the ones directly driving the autoimmune response against neuromuscular endplates. METHODS We identified patients with acetylcholine receptor antibody-positive (AChR+) MG and CLL or monoclonal B-cell lymphocytosis (MBL), a precursor to CLL, and described their clinical features, including treatment responses. We generated recombinant monoclonal antibodies (mAbs) corresponding to the B-cell receptors of the CLL phenotype B cells and screened them for autoantigen binding. RESULTS A computational immune cell screen revealed a subgroup of 5/38 patients with MG and 0/21 healthy controls who displayed a CLL-like B-cell phenotype. In follow-up hematologic flow cytometry, 2 of these 5 patients were diagnosed with an MBL. An additional patient with AChR+ MG as a complication of manifest CLL presented at our neuromuscular clinic and was successfully treated with the anti-CD20 therapy obinutuzumab plus chlorambucil. We investigated the specificities of expanding CLL-like B-cell clones to assess a direct causal link between the 2 diseases. However, we observed no reactivity of the clones against the AChR, antigens at the neuromuscular junction, or other common autoantigens. DISCUSSION Our study suggests that AChR autoantibodies are produced by nonmalignant, polyclonal B cells The new anti-CD20 treatment obinutuzumab might be considered in effectively treating AChR+ MG. CLASSIFICATION OF EVIDENCE This is a single case study and provides Class IV evidence that obinutuzumab is safe to use in patients with MG.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Burkhard Becher
- From the Institute of Experimental Immunology (F.I., M.L., S.K., T.W., S.M., B.S., B.B.), University of Zurich, Switzerland; Department of Neurology (F.I., B.S.), University Hospital Zurich, Switzerland; Institute for Research in Biomedicine (M.K., L.P., F.S., A.L.), Università Della Svizzera Italiana, Bellinzona, Switzerland; Institute of Microbiology (M.K., F.S.), ETH Zurich, Switzerland; Department of Medical Oncology and Hematology (C.C.W.), University Hospital Zurich and University of Zurich, Switzerland; and Nuffield Department of Clinical Neurosciences (M.W., P.W.), University of Oxford, United Kingdom.
| | - Bettina Schreiner
- From the Institute of Experimental Immunology (F.I., M.L., S.K., T.W., S.M., B.S., B.B.), University of Zurich, Switzerland; Department of Neurology (F.I., B.S.), University Hospital Zurich, Switzerland; Institute for Research in Biomedicine (M.K., L.P., F.S., A.L.), Università Della Svizzera Italiana, Bellinzona, Switzerland; Institute of Microbiology (M.K., F.S.), ETH Zurich, Switzerland; Department of Medical Oncology and Hematology (C.C.W.), University Hospital Zurich and University of Zurich, Switzerland; and Nuffield Department of Clinical Neurosciences (M.W., P.W.), University of Oxford, United Kingdom.
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Zhang Y, Varnadoe C, Tandon A, Forsyth P, Komrokji R, Sokol L. Myasthenia Gravis and Large Granular Lymphocytic Leukemia: a rare association. Leuk Res Rep 2020; 14:100226. [PMID: 33094093 PMCID: PMC7568180 DOI: 10.1016/j.lrr.2020.100226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 10/04/2020] [Indexed: 11/18/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neuromuscular junction disorder sometimes observed in hematologic malignancies as a paraneoplastic syndrome. T-cell Large Granular Lymphocytic Leukemia (T-LGLL) is a rare lymphoproliferative clonal frequently associated with autoimmune disorders. Here we report two patients with T-LGLL who developed MG. In both patients the MG was bulbar without generalized weakness and did not involve the thymus. The treatment of T-LGLL led to the resolution of MG symptoms and decrease in acetylcholine receptor antibody titers in both patients suggesting a causative association.
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Affiliation(s)
- Yumeng Zhang
- Morsani College of Medicine, University of South Florida, Tampa Fl 33612
| | | | - Ankita Tandon
- Morsani College of Medicine, University of South Florida, Tampa Fl 33612
| | | | | | - Lubomir Sokol
- Moffitt Cancer Center, Tampa FL 33612
- Corresponding Author: Dr. Lubomir Sokol, Department of Malignant Hematology, Moffitt Cancer Center, 12902 USF Magnolia Dr, Tampa FL 33612
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Ohara M, Ozaki K, Ohkubo T, Yamada A, Numasawa Y, Tanaka K, Tomii S, Ishibashi S, Sanjo N, Yokota T. Myasthenia Gravis Complicated with Peripheral T-cell Lymphoma, Not Otherwise Specified (PTCL-NOS), Following Thymectomy and Longstanding Tacrolimus Therapy. Intern Med 2018; 57:601-604. [PMID: 29269644 PMCID: PMC5849561 DOI: 10.2169/internalmedicine.9167-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Myasthenia gravis (MG), a neuromuscular junction autoimmune disease, sometimes complicates second malignancies; however, T-cell lymphoproliferative disorders have rarely been reported. A 55-year-old man, who received oral tacrolimus and prednisolone for MG for 16 years after thymectomy, presented with left abdominal pain, lymphadenopathy, and splenomegaly. A lymph node biopsy revealed peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS). This is the first report of oral tacrolimus leading to a T-cell lymphoproliferative disorder in patient without a history of transplantation. Physicians should be aware of the possibility of rare T-cell lymphoproliferative disorders, such as PTCL-NOS, occurring as complications in MG patients on immunosuppressive regimens after thymectomy.
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Affiliation(s)
- Masahiro Ohara
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Kokoro Ozaki
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Takuya Ohkubo
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Akane Yamada
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Yoshiyuki Numasawa
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Keisuke Tanaka
- Department of Hematology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Shohei Tomii
- Department of Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Satoru Ishibashi
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Nobuo Sanjo
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Takanori Yokota
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
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Yeh JH, Lin CC, Chen YK, Sung FC, Chiu HC, Kao CH. Excessive risk of cancer and in particular lymphoid malignancy in myasthenia gravis patients: a population-based cohort study. Neuromuscul Disord 2013; 24:245-9. [PMID: 24332676 DOI: 10.1016/j.nmd.2013.11.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 11/08/2013] [Accepted: 11/14/2013] [Indexed: 01/20/2023]
Abstract
The exact relationship between myasthenia gravis (MG) and extrathymic malignancies has not been established thus far. Occasional cases of MG have been reported in association with lymphoma or other lymphoproliferative disorders. To determine the risk of extrathymic malignancy with particular attention on lymphoid malignancy for MG patients in a large cohort representing 99% of the Taiwan population, claims data from the Taiwan National Health Insurance Database were used to conduct retrospective cohort analyses. The study cohort comprised 3671 MG patients who were 10-fold frequency matched by age and sex, and assigned the same index year without MG. Cox proportional hazard regression analysis was conducted to estimate the risk of cancer. The MG cohort had a 1.74-fold increased risk of developing cancer compared to the comparison cohort (HR=1.74, 95% CI=1.47-2.05). After adjusting for confounders and relative to the cohort, patients with MG had a 2.27-fold increased risk of developing lymphoid malignancies (HR=2.27, 95% CI=1.06-4.88) and a 118.47-fold increased risk of thymus cancer (HR=118.47, 95%=42.57-329.71). This population based retrospective case-control study confirms and extends previous observations on the association between MG and lymphoid malignancies.
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Affiliation(s)
- Jiann-Horng Yeh
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Che-Chen Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Yen-Kung Chen
- Department of Nuclear Medicine and PET Center, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Fung-Chang Sung
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medicine Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Hou-Chang Chiu
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Clinical Medicine Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan.
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Rezania K, Soliven B, Baron J, Lin H, Penumalli V, van Besien K. Myasthenia gravis, an autoimmune manifestation of lymphoma and lymphoproliferative disorders: case reports and review of literature. Leuk Lymphoma 2011; 53:371-80. [PMID: 21864038 DOI: 10.3109/10428194.2011.615426] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kourosh Rezania
- Department of Neurology, University of Chicago Medical Center, Chicago, IL 60637, USA.
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Koussa S, Rustom M. [Association between myasthenia gravis and extrathymic non-Hodgkin's lymphoma]. Rev Neurol (Paris) 2010; 166:752-3. [PMID: 20471662 DOI: 10.1016/j.neurol.2010.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2010] [Accepted: 03/03/2010] [Indexed: 11/26/2022]
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Schmidt D. Signs in ocular myasthenia and pseudomyasthenia Differential diagnostic criteria: A clinical review. Neuroophthalmology 2009. [DOI: 10.3109/01658109509044590] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Rey J, Attarian S, Disdier P, Feuillet L, Azulay JP, Pouget J. [Myasthenia gravis and chronic lymphocytic leukemia: a lucky association?]. Rev Med Interne 2001; 22:1129-30. [PMID: 11817127 DOI: 10.1016/s0248-8663(01)00480-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
MESH Headings
- Autoimmune Diseases/pathology
- Diagnosis, Differential
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Middle Aged
- Myasthenia Gravis/complications
- Myasthenia Gravis/diagnosis
- Myasthenia Gravis/pathology
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Uner AH, Abali H, Engin H, Akyol A, Ruacan S, Tan E, Güllü I, Altundağ K, Güler N. Myasthenia gravis and lymphoblastic lymphoma involving the thymus: a rare association. Leuk Lymphoma 2001; 42:527-31. [PMID: 11699420 DOI: 10.3109/10428190109064612] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Myasthenia gravis (MG) is an autoimmune neuromuscular junction disease. An association between thymic epithelial neoplasms and MG is well known. However, it is rarely associated with hematologic malignancies. In particular, very few cases of lymphoblastic lymphoma involving the thymus and MG have been reported. Here we report a case T-cell lymphoblastic lymphoma involving the thymus who developed MG after the initial diagnosis. The patient initially presented with a mediastinal mass which was diagnosed as lymphoblastic lymphoma. MG was diagnosed during leukemic relapse in this patient and was based on clinical presentation and neurophysiologic studies including single fiber electromyography (EMG) and repetitive nerve stimulation tests. In contrast to the other cases with such an association, the myasthenic symptoms presented nine months after the diagnosis of lymphoma by thymectomy. The patient had a highly aggressive clinical course and was resistant to various chemotherapy regimens.
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Affiliation(s)
- A H Uner
- Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey.
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Hildebrand J, Van Nechel C, Zanen A. Neuro-ophthalmological paraneoplastic syndromes: a review. Neuroophthalmology 2001. [DOI: 10.1076/noph.26.2.67.10306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Ridyard AE, Rhind SM, French AT, Munro EA, Hill PB. Myasthenia gravis associated with cutaneous lymphoma in a dog. J Small Anim Pract 2000; 41:348-51. [PMID: 11002936 DOI: 10.1111/j.1748-5827.2000.tb03216.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A middle-aged golden retriever presenting with exercise intolerance and multifocal cutaneous nodules was diagnosed as having non-epitheliotropic cutaneous lymphoma with concurrent myasthenia gravis. Treatment with corticosteroids induced short-term remission of the lymphoma and alleviation of myasthenic signs.
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Affiliation(s)
- A E Ridyard
- Department of Veterinary Clinical Studies, Royal Dick School of Veterinary Studies, The University of Edinburgh Hospital for Small Animals, Easter Bush Veterinary Centre, Roslin, Midlothian
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Mohri H, Harano H, Okubo T. Concomitant association of myasthenia gravis and pure red cell aplasia after chemotherapy for Hodgkin's disease. Am J Hematol 1997. [DOI: 10.1002/(sici)1096-8652(199704)54:4<343::aid-ajh19>3.0.co;2-c] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Correale J, Monteverde DA, Bueri JA, Reich EG. Peripheral nervous system and spinal cord involvement in lymphoma. Acta Neurol Scand 1991; 83:45-51. [PMID: 1849335 DOI: 10.1111/j.1600-0404.1991.tb03957.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Nine-hundred-eighty-nine patients with diagnosis of lymphoma were studied. Forty-six cases (4.6%) had compressions of the spinal cord or roots. Forty-two patients (4.2%) had Herpes zoster virus infections, which in 6 cases were of disseminated type. The major predisposing factors for infection were: advanced stage of lymphoma, previous systemic chemotherapy and splenectomy. Toxic polyneuropathy secondary to chemotherapy was found in 39 patients (3.9%). In 14 cases, the polyneuropathic symptoms were the main complaint (Group 1), while in the remaining 25 cases the diagnosis was made during neurological consultations because of unrelated symptoms (Group 2). Both groups did not have significant differences in the total dose of chemotherapy received. The electrophysiological studies showed an axonal neuropathy in both groups. The discontinuation of chemotherapy was found to be a limiting factor in the appearance of neuropathic symptoms. Other less frequent forms of involvement were: compression of peripheral nerves or nerve plexi from lymphadenopathies (3 cases), radiation myelopathy (1 case), and Guillain-Barré Syndrome associated with Hodgkin's Lymphoma (1 case).
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Affiliation(s)
- J Correale
- Division of Neurology, José María Ramos Mejía, Hospital, Buenos Aires, Argentina
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