1
|
Prud'homme L, Gitiaux C, Barnerias C, Orssaud C, Bremond-Gignac D, Robert MP. [Pediatric myasthenia with ocular involvement]. J Fr Ophtalmol 2024; 47:104202. [PMID: 38723375 DOI: 10.1016/j.jfo.2024.104202] [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: 06/20/2023] [Revised: 11/30/2023] [Accepted: 01/22/2024] [Indexed: 09/15/2024]
Abstract
PURPOSE Myasthenia is a rare disease in children, with an estimated incidence of 1 to 5 per million children. However, the potential severity of its consequences and the existence of specific treatments require prompt diagnosis by pediatric ophthalmologists. METHODS Retrospective review of patient records. Patients were identified from a rare disease database. Patients under the age of 18 years with confirmed diagnosis of myasthenia and ocular symptoms seen in a specialized clinic between 2005 and 2021 were included. RESULTS Twenty-six (16 girls) with confirmed myasthenia and ocular symptoms were included. Ten patients had definite autoimmune myasthenia gravis (AIMG); 6 had suspected AIMG with negative antibody testing. Six patients had definite congenital myasthenic syndrome (CMS); 4 had suspected CMS with no evidence of mutation. Mean age at diagnosis of myasthenia was 5 years-3 years and 5 months for CMS and 6 years and 3 months for AIMG. Male to female (M:F) ratio was 6/10 for autoimmune myasthenia gravis and 4/6 for CMS. Ptosis was present in all cases; strabismus in 21 patients (68%). The clinical forms of myasthenia were ocular myasthenia in 12 patients (10 AIMG and 2 CMS), generalized in 12 patients (7 CMS and 5 AIMG) and secondary generalization of ocular myasthenia in 2 patients (2 AIMG). DISCUSSION These results are based on only 26 cases, which can be explained by the rarity of this diagnosis in children. As in adults, the first signs are often ophthalmologic - ptosis alone or associated with strabismus. Diagnosis is difficult because of the absence of clinical signs, laboratory tests or electrophysiological signs with high sensitivity. Thus, the work-up may remain completely negative in secondarily proven forms. In addition, electroneuromyograms and oculomotor recordings in small children are more difficult to perform than in adults. For these reasons, the clinical examination is essential. In the case of strong suspicion, all additional medical examinations are carried out in a day unit, in order to reach a positive diagnosis of myasthenia. The so-called "congenital" forms, which are genetic, are proportionately higher than in adults, and diagnosis and treatment are often more difficult than in the classic autoimmune forms. CONCLUSION Myasthenia can affect children from a very young age and can present as ptosis, initially isolated or associated with strabismus. Diagnosis and treatment may be difficult and should be organized in specialized centers.
Collapse
Affiliation(s)
- L Prud'homme
- Département d'ophtalmologie 2, hôpital national d'ophtalmologie des Quinze-Vingts, Paris, France; Service d'ophtalmologie, Paris-Cité University, hôpital universitaire Necker-Enfants-Malades, AP-HP, Paris, France.
| | - C Gitiaux
- Département de neurologie pédiatrique et de neurophysiologie pédiatrique, hôpital Necker-Enfants-Malades, Paris, France; Centre de référence pour les maladies neuromusculaires « Garches-Necker-Mondor-Hendaye », Créteil, France; Département génétique et développement, institut Cochin, université Paris-Descartes, Paris, France
| | - C Barnerias
- Centre de référence pour les maladies neuromusculaires, Filnemus, EuroNMD, hôpital Necker-Enfants-Malades, AP-HP, Paris, France
| | - C Orssaud
- Unité ophtalmologie, service d'ophtalmologie, centre de référence des maladies rares en ophtalmologie (OPHTARA), hôpital européen Georges-Pompidou (HEGP), hôpital Necker-Enfants-Malades, 75015 Paris, France
| | - D Bremond-Gignac
- Service d'ophtalmologie, Paris-Cité University, hôpital universitaire Necker-Enfants-Malades, AP-HP, Paris, France; Centre de recherche des Cordeliers, Sorbonne Paris-Cité University, Paris, France
| | - M P Robert
- Service d'ophtalmologie, Paris-Cité University, hôpital universitaire Necker-Enfants-Malades, AP-HP, Paris, France; Centre de recherche des Cordeliers, Sorbonne Paris-Cité University, Paris, France
| |
Collapse
|
2
|
Zhu M, Wang Y, Xu X, Guo X, Mao Y, Gao F. Small extracellular vesicle microRNAs in pediatric myasthenia gravis plasma and skeletal muscle. Postgrad Med J 2024; 100:488-495. [PMID: 38449066 DOI: 10.1093/postmj/qgae015] [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: 09/09/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND The diagnosis of myasthenia gravis (MG) in children remains difficult. Circulating small extracellular vesicle (sEV)-derived miRNAs (sEV-miRNAs) have been recognized as biomarkers of various diseases and can be excreted by different cell types. These biomarker candidates also play a vital role in autoimmune diseases via intercellular communication. METHODS In the present study, we used sEV isolation and purification methods to extract the plasma-derived sEV-miRNAs from children with MG and healthy controls. A small RNA sequencing analysis confirmed the miRNA expression features in plasma-derived sEVs from MG patients. The miRNA expression analysis in vitro was determined using microarray analysis. The enrichment and network analyses of altered sEV-miRNAs were performed using miRNA databases and Database for Annotation, Visualization, and Integrated Discovery website. Quantitative real-time polymerase chain reaction was performed for validation of sEV-miRNA. The diagnostic power of altered sEV-miRNAs was evaluated using receiver operating characteristic curve analyses. RESULTS Twenty-four sEV-miRNAs with altered expression level were identified between groups by DESeq2 method. The miRNAs were extracted from the sEVs, which were isolated from human primary skeletal muscle cell culture treated with mAb198. The target genes and enriched pathways of sEV-miRNAs partially overlapped between cell supernatant and plasma samples. The significantly downregulated miR-143-3p was validated in quantitative real-time polymerase chain reaction analysis. CONCLUSIONS For the first time, we report that plasma-derived sEV-miRNAs may act as novel circulating biomarkers and therapeutic targets in pediatric MG.
Collapse
Affiliation(s)
- Mengying Zhu
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
- National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
| | - Yilong Wang
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
- National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
| | - Xuebin Xu
- National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
| | - Xiaotong Guo
- National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
| | - Yuchen Mao
- National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
| | - Feng Gao
- Department of Neurology, Children's Hospital, Zhejiang University School of Medicine, Zhejiang, Hangzhou 310052, China
| |
Collapse
|
3
|
Özsoy Ö, Cinleti T, Günay Ç, Sarıkaya Uzan G, Giray Bozkaya Ö, Çağlayan AO, Hız Kurul S, Yiş U. Genetic, serological and clinical evaluation of childhood myasthenia syndromes- single center subgroup analysis experience in Turkey. Acta Neurol Belg 2023; 123:2325-2335. [PMID: 37656362 DOI: 10.1007/s13760-023-02370-3] [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: 04/04/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Congenital myasthenic syndrome is a disease that occurs due to several types such as mutations in different pre-synaptic, synaptic, post-synaptic proteins and, glycosylation defects associated with congenital myopathy. Juvenile myasthenia gravis is an autoimmune condition usually caused by antibodies targeting the acetylcholine receptor. AIMS Our objective is to conduct an analysis on the subgroup traits exhibited by patients who have been diagnosed with congenital myasthenic syndrome and juvenile myasthenia gravis, with a focus on their long-term monitoring and management. METHODS This study was conducted on children diagnosed with myasthenia gravis, who were under the care of Dokuz Eylul University's Department of Pediatric Neurology for a period of ten years. RESULTS A total of 22 (12 congenital myasthenic syndrome, 10 juvenile myasthenia gravis) patients were identified. Defects in the acetylcholine receptor (6/12) were the most common type in the congenital myasthenic syndrome group. Basal-lamina-related defects (5/12) were the second most prevalent. One patient had a GFPT1 gene mutation (1/12). Patients with ocular myasthenia gravis (n = 6) exhibited milder symptoms. In the generalized myasthenia gravis group (n = 4), specifically in postpubertal girls, a more severe clinical progression was observed, leading to the implementation of more aggressive treatment strategies. CONCLUSION This study highlights that clinical recognition of congenital myasthenic syndrome and knowledge of related genes will aid the rapid diagnosis and treatment of these rare neuromuscular disorders. Findings in the juvenile myasthenia gravis group demonstrate the impact of pubertal development and the need for timely and appropriate active therapy, including thymectomy, to improve prognosis.
Collapse
Affiliation(s)
- Özlem Özsoy
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey.
| | - Tayfun Cinleti
- Department of Pediatric Genetics, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Çağatay Günay
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Gamze Sarıkaya Uzan
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Özlem Giray Bozkaya
- Department of Pediatric Genetics, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Ahmet Okay Çağlayan
- Department of Medical Genetics, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
- Department of Molecular Medicine, Institute of Health Sciences, Dokuz Eylül University, İzmir, Turkey
| | - Semra Hız Kurul
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
- İzmir Biomedicine and Genome Center, Dokuz Eylül University Health Campus, İzmir, Turkey
- İzmir International Biomedicine and Genome Institute, Dokuz Eylül University, İzmir, Turkey
| | - Uluç Yiş
- Department of Pediatric Neurology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| |
Collapse
|
4
|
Zhang Y, Zhang M, Zhang L, Zhou S, Li W. Long-term efficacy and safety of tacrolimus in young children with myasthenia gravis. J Clin Neurosci 2023; 116:93-98. [PMID: 37669613 DOI: 10.1016/j.jocn.2023.08.022] [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: 04/10/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVE This study was performed to evaluate the efficacy and long-term safety of tacrolimus for young children with myasthenia gravis (MG). METHODS Children with corticosteroids (CSs)-ineffective, CSs-dependent or CSs-intolerable MG treated with tacrolimus for at least one year were recruited. The Myasthenia Gravis Foundation of America (MGFA) clinical classification and MGFA post-intervention status (MGFA-PIS) were used to evaluate before tacrolimus administration and at the last visit, respectively. MG Activities of Daily Living (MG-ADL) score and the dose of prednisone were recorded. Patients were divided into responders and poor responders based on changes in MG-ADL score to investigate the factors that affected tacrolimus efficacy. Unfavorable events were recorded. RESULTS Twenty-one patients with MG were enrolled. The median age of starting tacrolimus was 8.7 (range 2.2-15.1) years old. At the last visit, 15 patients (71.4%) achieved minimal manifestation (MM) or better status. The symptoms evaluated by MG-ADL improved significantly one month after initiating tacrolimus (p<0.05) and the dose of prednisone decreased significantly three months later (p<0.05), and it continued to improve throughout the study. Thirteen patients (61.9%) were ultimately weaned off prednisone. Compared with 16 responders, 5 poor responders had lower MG-ADL scores. MG-ADL score was the only clinical factor of tacrolimus efficacy. Intraocular pressure and transient urine microprotein were present in one patient. CONCLUSION A course of tacrolimus of more than one year was effective and well-tolerated in young children with MG, and tacrolimus improved MG symptoms and reduced the dose and adverse events of oral prednisone.
Collapse
Affiliation(s)
- Yan Zhang
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, China; Department of Neurology, Children's Hospital of Fudan University at Xiamen, State-Level Regional Children's Medical Center, China
| | - Min Zhang
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, China
| | - Linmei Zhang
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, China
| | - Shuizhen Zhou
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, China.
| | - Wenhui Li
- Department of Neurology, Children's Hospital of Fudan University, National Children's Medical Center, China.
| |
Collapse
|
5
|
Molimard A, Gitiaux C, Barnerias C, Audic F, Isapof A, Walther-Louvier U, Cances C, Espil-Taris C, Davion JB, Quijano-Roy S, Grisel C, Chabrol B, Desguerre I. Rituximab Therapy in the Treatment of Juvenile Myasthenia Gravis: The French Experience. Neurology 2022; 98:e2368-e2376. [PMID: 35314497 DOI: 10.1212/wnl.0000000000200288] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/10/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Corticosteroids are the first-line immunosuppressants in the management of juvenile myasthenia gravis despite their adverse effects. The place of new immunosuppressive therapies is not clearly defined by the last international consensus held in March 2019, due to the lack of clinical trials. The aim of this study is to describe the use of rituximab, its efficacy and safety in 8 main pediatric centers of the French neuromuscular reference network in order to propose a new place in the therapeutic strategy of juvenile myasthenia gravis. METHOD We conducted a retrospective multicenter study from January 1, 2009 to April 30, 2020, including a large cohort of children with myasthenia gravis in 8 main French pediatric reference centers of the Filnemus network. The type of myasthenia, the different lines of immunosuppressive treatment and the clinical course of the patients were collected. To evaluate the efficacy of rituximab, we studied the clinical course of patients on immunosuppressive therapy. Outcome was defined as the clinical and therapeutic status of patients at the last visit: stable without immunosuppressants, stable with immunosuppressants or unstable. RESULTS We included 74 patients: 18 children with ocular form and 56 children with generalized form. Of the 37 patients who required immunosuppressive therapy, 27 were treated with rituximab. Patients treated with rituximab had a better outcome than patients treated with conventional immunosuppressants (p = 0.006). The use of rituximab as a first-line immunosuppressant showed a better efficacy with a discontinuation of immunosuppressants in 75% of patients (vs. 25%, p=0.04) and resulted cortisone sparing (42% vs. 92%, p=0.03) compared with rituximab treatment as a second or third-line immunosuppression. Rituximab was well tolerated; no adverse effect was observed. CONCLUSION The use of rituximab has increased in France over the last 10 years as first line immunosuppressant. This study suggests a good tolerability and efficacy of rituximab in juvenile myasthenia gravis. Early use appears to improve outcomes and facilitate cortisone-sparing in antibody-positive generalized juvenile myasthenia. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for children with MG rituximab is effective and well tolerated.
Collapse
Affiliation(s)
| | - Cyril Gitiaux
- Centre de Référence des Maladies Neuromusculaires Nord/Ile de France/Est, Service de Neurologie pédiatrique, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Christine Barnerias
- Centre de Référence des Maladies Neuromusculaires Nord/Ile de France/Est, Service de Neurologie pédiatrique, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Frédérique Audic
- Centre de Référence des Maladies Neuromusculaires de l'enfant PACARARE, Service de Neuropédiatrie, Hôpital Timone Enfants, 264 rue Saint Pierre, 13385, Marseille Cedex 5
| | - Arnaud Isapof
- Centre de Référence des Maladies Neuromusculaires Nord/Ile de France/Est, Service de Neuropédiatrie, Hôpital Trousseau, APHP, Paris, France
| | - Ulrike Walther-Louvier
- Centre de Référence des Maladies Neuromusculaires AOC, Service de Neuropédiatrie CHU Montpellier, Montpellier, France
| | - Claude Cances
- Centre de Référence des Maladies Neuromusculaires AOC, Unité de Neurologie Pédiatrique, Hôpital des Enfants CHU Toulouse, Toulouse, France
| | - Caroline Espil-Taris
- Centre de Référence des Maladies Neuromusculaires AOC, Unité de Neurologie pédiatrique, CHU Pellegrin, Bordeaux, France
| | - Jean-Baptiste Davion
- Centre de référence des maladies neuromusculaires Nord Est Ile de France, CHU de Lille, Lille, France
| | - Susana Quijano-Roy
- Centre de Référence des Maladies Neuromusculaires Nord/Ile de France/Est, Hôpital Raymond Poincaré, APHP, Garches, France
| | - Coraline Grisel
- Service de pédiatrie, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Brigitte Chabrol
- Centre de Référence des Maladies Neuromusculaires de l'enfant PACARARE, Service de Neuropédiatrie, Hôpital Timone Enfants, 264 rue Saint Pierre, 13385, Marseille Cedex 5
| | - Isabelle Desguerre
- Centre de Référence des Maladies Neuromusculaires Nord/Ile de France/Est, Service de Neurologie pédiatrique, Hôpital Necker-Enfants Malades, APHP, Paris, France
| |
Collapse
|
6
|
Heckmann JM, Europa TA, Soni AJ, Nel M. The Epidemiology and Phenotypes of Ocular Manifestations in Childhood and Juvenile Myasthenia Gravis: A Review. Front Neurol 2022; 13:834212. [PMID: 35280301 PMCID: PMC8904732 DOI: 10.3389/fneur.2022.834212] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/24/2022] [Indexed: 11/28/2022] Open
Abstract
Myasthenia gravis (MG) appears to have a similar incidence among adult populations worldwide. However, epidemiological and phenotypic differences have been noted among children and juveniles with MG. We reviewed the literature on childhood- and juvenile-onset MG among different populations, with the focus on ocular involvement, antibody profiles, the genetic susceptibility to juvenile MG phenotypes, the use of immune treatments, and the reported responses of extraocular muscles to therapies. Although epidemiological studies used different methodologies, reports from Asia, compared to Europe, showed more than two-fold higher proportions of prepubertal onset (before 12 years) vs. postpubertal-onset juveniles with MG. Compared to European children, ocular MG was 4-fold more frequent among Asian children, and 2–3-fold more frequent among children with African ancestry both in prepubertal and postpubertal ages at onset. These results suggest genetic influences. In Asia, HLA-B*46 and DRB1*09 appeared overrepresented in children with ocular MG. In Europe, children with MG had a significantly higher rate of transforming from ocular to generalized disease and with an overrepresentation of HLADRB1*04. Although treatment regimens vary widely and the responses to immune therapies of the ocular muscles involved in MG were generally poorly described, there were indications that earlier use of steroid therapy may have better outcomes. Reports of treatment-resistant ophthalmoplegia may be more frequent in African and Asian juvenile MG cohorts compared to Europeans. Genetic and muscle gene expression studies point to dysregulated muscle atrophy signaling and mitochondrial metabolism pathways as pathogenetic mechanisms underpinning treatment-resistant ophthalmoplegia in susceptible individuals. In conclusion, phenotypic differences in juveniles with ocular manifestations of MG were evident in different populations suggesting pathogenetic influences. Treatment responses in MG-associated ocular disease should attract more careful descriptive reports. In MG, extraocular muscles may be vulnerable to critical periods of poor force generation and certain individuals may be particularly susceptible to developing treatment-resistant ophthalmoplegia. The development of prognostic biomarkers to identify these susceptible individuals is an unmet need.
Collapse
Affiliation(s)
- Jeannine M Heckmann
- Division of Neurology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Neurology Research Group, University of Cape Town (UCT) Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Tarin A Europa
- Division of Neurology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Neurology Research Group, University of Cape Town (UCT) Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Aayesha J Soni
- Division of Neurology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Melissa Nel
- Neurology Research Group, University of Cape Town (UCT) Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
7
|
Jain R, Aulakh R. Pediatric Ocular Myasthenia Gravis: A Review. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1721401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractPediatric ocular myasthenia gravis (OMG) is difficult to diagnose and manage, owing to its rarity and low index of suspicion in the early stage of the disease. Also, many other conditions having similar presentation cause a further delay in diagnosis. In this review, we highlighted various pointers in history and described bedside clinical tests that can aid in its timely diagnosis. The antibody spectrum in myasthenia is ever increasing and includes anti-muscle specific kinase and low-density lipoprotein-receptor related protein 4 antibodies in addition to acetylcholine receptor antibodies besides many others. However, pediatric OMG patients often test negative for all three antibodies, making the diagnosis even more difficult in triple seronegative patients. Edrophonium and electrophysiological tests, which help in confirming myasthenia in adults, have a limited utility in diagnosing pediatric ocular myasthenia cases. Various practical difficulties are encountered like nonavailability of edrophonium, risk of bradycardia associated with neostigmine use and its lower sensitivity, noncooperative children, and limited technical expertise in performing electrophysiological tests in children. In this article, we described a pragmatic approach to diagnose pediatric OMG along with the important aspects of its management.
Collapse
Affiliation(s)
- Reena Jain
- Department of Pediatrics, Government Medical College & Hospital, Chandigarh, India
| | - Roosy Aulakh
- Department of Pediatrics, Government Medical College & Hospital, Chandigarh, India
| |
Collapse
|
8
|
Fc-Receptor Targeted Therapies for the Treatment of Myasthenia gravis. Int J Mol Sci 2021; 22:ijms22115755. [PMID: 34071155 PMCID: PMC8198115 DOI: 10.3390/ijms22115755] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 12/16/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease in which immunoglobulin G (IgG) antibodies (Abs) bind to acetylcholine receptors (AChR) or to functionally related molecules in the postsynaptic membrane at the neuromuscular junction. IgG crystallizable fragment (Fc)-mediated effector functions, such as antibody-dependent complement deposition, contribute to disease development and progression. Despite progress in understanding Ab-mediated disease mechanisms, immunotherapy of MG remained rather unspecific with corticosteroids and maintenance with immunosuppressants as first choice drugs for most patients. More specific therapeutic IgG Fc-based platforms that reduce serum half-life or effector functions of pathogenic MG-related Abs are currently being developed, tested in clinical trials or have recently been successfully translated into the clinic. In this review, we illustrate mechanisms of action and clinical efficacies of emerging Fc-mediated therapeutics such as neonatal Fc receptor (FcRn)-targeting agents. Furthermore, we evaluate prospects of therapies targeting classical Fc receptors that have shown promising therapeutic efficacy in other antibody-mediated conditions. Increased availability of Fc- and Fc receptor-targeting biologics might foster the development of personalized immunotherapies with the potential to induce sustained disease remission in patients with MG.
Collapse
|
9
|
Fisher KS, Gill J, Todd HF, Yang MB, Lopez MA, Abid F, Lotze T, Shah VS. Pediatric Autoimmune Ocular Myasthenia Gravis: Evaluation of Presentation and Treatment Outcomes in a Large Cohort. Pediatr Neurol 2021; 118:12-19. [PMID: 33684630 DOI: 10.1016/j.pediatrneurol.2021.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND In autoimmune myasthenia gravis (MG), autoantibodies target the neuromuscular junction. Ocular myasthenia gravis (OMG) is localized, affecting only extraocular and/or levator palpebrae muscles. OMG presents across all ages, varying in presentation, treatment modalities, and outcomes. Recently, there have been advances in MG/OMG treatment; their utilization and effectiveness are an important part of optimal disease management. METHODS We completed a retrospective chart review of children aged 18 years or younger with a confirmed diagnosis of OMG presenting from 2002 to 2019. RESULTS Forty-two patients were included with mean age at presentation of 8.5 years (2 to 18 years). Twenty-one patients (50%) had positive antibodies; 90% had acetylcholine receptor antibodies. Ten patients developed generalized symptoms with mean time to generalization of 13.6 months. Multiple logistic regression showed that older age of onset was a trend predictive factor (P = 0.054; odds ratio 1.17) for generalized disease. All patients were treated with pyridostigmine. Immunomodulating agents included steroids (15), mycophenolate mofetil (four), and intravenous immunoglobulin (one). Three patients underwent thymectomy. Twenty patients reached minimal manifestation status, and 12 achieved remission. Gender, race, and positive antibody status were not statistically significant predictors for advanced immunosuppressive therapy. CONCLUSIONS We summarize one of the largest cohorts of pediatric patients with OMG who have undergone up-to-date diagnostic and therapeutic regimens. The predictors of outcome and treatment pathway for OMG patients suggested by this report may be further elucidated by future prospective studies.
Collapse
Affiliation(s)
- Kristen S Fisher
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jason Gill
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | - Michael B Yang
- Division of Pediatric Ophthalmology, Abrahamson Pediatric Eye Institute, Cincinnati, Ohio; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael A Lopez
- Hess Pediatric Ophthalmology Specialist, St. Petersburg, Florida
| | - Farida Abid
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Timothy Lotze
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Veeral S Shah
- Division of Pediatric Ophthalmology, Abrahamson Pediatric Eye Institute, Cincinnati, Ohio; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio.
| |
Collapse
|
10
|
Ali M, Riad M, Adhikari P, Bhattarai S, Gupta A, Ali E, Mostafa JA. Association Between Myasthenia Gravis and Systemic Lupus Erythematosus as a Comorbid State. Cureus 2021; 13:e14719. [PMID: 34055558 PMCID: PMC8158067 DOI: 10.7759/cureus.14719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are autoimmune states which have presentational similitude. Both conditions test serologically positive for anti-nuclear antibodies and require exceptional differential diagnostic acumen to segregate one from the other. The hypothesized factors provoking these diseases may be immunological, genetic, hormonal, or environmental and can be better understood by large-scale controlled epidemiological studies. Biochemical factors such as variation in CXC (an α chemokine subfamily), CXCL13, and granulocyte-macrophage colony-stimulating factor levels are assumed to play a pivotal role in the pathogenesis of SLE and MG; however, further studies are required to understand their exact mechanism and effect on the underlying autoimmune diseases.
Following this, another precipitating factor for this overlap is believed to be thymectomy which is performed to eliminate MG symptoms. Although thymectomy is the effective treatment modality in MG patients, other findings and data support the view that this procedure may lead to the development of other autoimmune states such as SLE. It is evident from previously published data and case reports that patients with one autoimmune disease who underwent thymectomy contracted SLE and became more susceptible to other autoimmune diseases compared to the general population. Post-thymectomy follow-up of patients provides us with mechanistic clues for understanding the development of SLE-MG overlap; hence, in MG patients who have undergone thymectomy, any clinical and immune serological SLE suspicion should be carefully evaluated.
Collapse
Affiliation(s)
- Moeez Ali
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mohamed Riad
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Prakash Adhikari
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Sanket Bhattarai
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ashish Gupta
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Eiman Ali
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jihan A Mostafa
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| |
Collapse
|
11
|
Prior DE, Cooper BA, Zhang B, Ghosh PS. Developing outcome measures of disease activity in pediatric myasthenia. Muscle Nerve 2021; 63:751-757. [PMID: 33604899 DOI: 10.1002/mus.27208] [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: 09/13/2020] [Revised: 02/14/2021] [Accepted: 02/16/2021] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Pediatric myasthenia encompasses juvenile myasthenia gravis (JMG) and congenital myasthenic syndrome (CMS), which are chronic disorders with fluctuating symptoms amenable to medical therapy. Disease activity and treatment response may be difficult to assess, but, unlike adults, outcome measures have not been developed in children. METHODS The study was performed in children (0-18 years of age) at the neuromuscular center of a pediatric hospital over a 3-year period. Patients were recruited prospectively as part of their routine clinical care. Demographic data, diagnosis (JMG/CMS), and the following scales were recorded at each visit: Myasthenia Gravis Foundation of America (MGFA) class, Myasthenia Gravis Composite (MGC), and Pediatric Myasthenia-Quality of Life 15 (PM-QOL15). RESULTS Thirty-three patients (24 JMG, 9 CMS) were included in the study, 22 had two or more visits. We established known-groups validity of the MGC and PM-QOL15 scores as compared with the MGFA class. To establish concurrent validity, we constructed a receiver-operating characteristic curve and calculated threshold values of MGC and PM-QOL15 with optimal sensitivity and specificity for identifying a patient with more severe (MGFA III or higher) disease. Finally, we demonstrated the concordance between the MGC and PM-QOL15 by their statistically significant positive Pearson and Spearman correlations. DISCUSSION Our study suggests that MGC and PM-QOL15 are important disease outcome measures in pediatric myasthenia that are easy to administer and provide reliable assessment of disease activity in the clinic setting. Further studies are needed to validate their use for pediatric clinical research trials.
Collapse
Affiliation(s)
- Devin E Prior
- Department of Neurology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | | | - Bo Zhang
- Department of Neurology and ICCTR Biostatistics and Research Design Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Partha S Ghosh
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
12
|
Incidence, mortality, and economic burden of myasthenia gravis in China: A nationwide population-based study. LANCET REGIONAL HEALTH-WESTERN PACIFIC 2020; 5:100063. [PMID: 34327399 PMCID: PMC8315547 DOI: 10.1016/j.lanwpc.2020.100063] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 02/06/2023]
Abstract
Background Myasthenia gravis (MG) is the most common primary disorder of neuromuscular transmission, but the incidence of MG in China is unknown. We conducted the first nationwide study to determine the incidence and mortality rates of MG in all age groups at the national level in China. Methods This national population-based registry study is based on the database of the Hospital Quality Monitoring System of National Health Commission, which covers 1665 hospitals providing myasthenia gravis care in 31 provinces and municipalities across China. 94,638 hospital admissions for 59,243 myasthenia gravis patients were identified from January 1st, 2016 to December 31st, 2018. Myasthenia gravis was identified by ICD-10 codes (G70). Incidence of myasthenia gravis was stratified by age, sex, and province. Findings Of 59,243 patients, 30,503 individuals with myasthenia gravis were newly diagnosed. Age and sex adjusted incidence of myasthenia gravis was 0.68 per 100,000 person-years, with highest in the age group of 70–74 years. The incidence in females was 0.76 per 100,000 and 0.60 per 100,000 in males. The admission mortality rate was 14.69‰. Respiratory failure was the leading cause of death in patients with myasthenic crisis. There were 14,840 patients with thymomas, encompassing 14,636 (26.5%) adults and 204 (7.1%) juveniles. 9453 (63.7%) patients with thymomas underwent thymomectomy. The median length of hospital stay was 8 days (interquartile range (IQR) 4 to 15 days) with median hospitalization cost $1037 (IQR $493 to $2925). The Basic Medical Insurance was the most common payment method, covering 67.4% of patients. Interpretation The age and sex adjusted incidence of MG was 0.68 per 100,000 person-years in China. The admission mortality rate was 14.69‰. Most cases of new onset MG occurred in the seventh decade of life. Funding National Science Foundation of China (91642205, and 81830038); Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing
Collapse
|
13
|
Grasso F, De Leonibus L, Bertozzi M, Sica M, Angotti R, Luzzi L, Molinaro F, Messina M, Paladini P. Robotic-assisted thoracoscopy thymectomy for juvenile myasthenia gravis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
14
|
Katzberg HD, Vajsar J, Vezina K, Qashqari H, Selvadurai S, Chrestian N, Khayat A, Ryan CM, Narang I. Respiratory Dysfunction and Sleep-Disordered Breathing in Children With Myasthenia Gravis. J Child Neurol 2020; 35:600-606. [PMID: 32484036 DOI: 10.1177/0883073820924213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The purpose of this study was to prospectively evaluate sleep patterns and the presence of sleep-disordered breathing in children with myasthenia gravis. We further aimed to examine the relationship between sleep and daytime respiratory function using spirometry tests including upright and supine forced vital capacity, sniff nasal inspiratory pressure, and maximal inspiratory pressure. METHODS Eleven children between 3 and 18 years old with confirmed myasthenia gravis were recruited from The Hospital for Sick Children Neuromuscular Clinic in this prospective observational study. After informed consent was obtained, patients underwent a comprehensive clinical assessment with collection of anthropometric data. Following this, all subjects performed pulmonary function tests, overnight polysomnography and completed the Epworth Sleepiness Scale questionnaire. RESULTS Two of eleven children who reported no symptoms of sleep disordered breathing were diagnosed with mild to moderate obstructive sleep apnea. Pulmonary function tests showed abnormal maximal inspiratory pressure in 6 of 11 patients, whereas seated forced vital capacity as well as seated to supine forced vital capacity ratios were normal in the entire group. CONCLUSIONS In our small group of pediatric myasthenia gravis subjects, there was an unexpected finding of obstructive sleep apnea in 2 of the 11 patients studied. Maximal inspiratory pressure appears to be a more sensitive method of detecting abnormalities compared to upright or seated forced vital capacity. A larger multicenter study is needed to validate our findings and to determine the impact of obstructive sleep apnea in the pediatric myasthenia gravis population as well as risk factors associated with sleep disordered breathing.
Collapse
Affiliation(s)
- Hans D Katzberg
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Jiri Vajsar
- Department of Pediatrics, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Kevin Vezina
- Department of Pediatrics, Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Heba Qashqari
- Department of Pediatrics, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Selvadurai
- Department of Pediatrics, Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas Chrestian
- Department of Pediatrics, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah Khayat
- Department of Pediatrics, Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Clodagh M Ryan
- Department of Medicine, Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Indra Narang
- Department of Pediatrics, Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
15
|
Affiliation(s)
| | - Sheebu V Chacko
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Shabana Yusuf
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| |
Collapse
|
16
|
242nd ENMC International Workshop: Diagnosis and management of juvenile myasthenia gravis Hoofddorp, the Netherlands, 1-3 March 2019. Neuromuscul Disord 2020; 30:254-264. [PMID: 32173249 DOI: 10.1016/j.nmd.2020.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/03/2020] [Indexed: 12/13/2022]
|
17
|
Xu L, Castro D, Reisch JS, Iannaccone ST. Response to treatment in pediatric ocular myasthenia gravis. Muscle Nerve 2019; 61:226-230. [PMID: 31650555 DOI: 10.1002/mus.26745] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Juvenile myasthenia gravis (JMG), a pediatric autoimmune neuromuscular junction disorder, includes generalized (GMG), and ocular (OMG) variants. We sought to determine whether differences existed between OMG and GMG children regarding demographics or treatment response. METHODS We performed retrospective analysis of 60 children with JMG seen between 1990 and 2018. Osserman scores were used to define OMG and GMG. The myasthenia scale of Millichap and Dodge was used to assess treatment responses. RESULTS There were no differences between GMG and OMG regarding time interval from disease onset to prednisone initiation (P = .42), or treatment response according to Millichap and Dodge (P = .12). Compared with GMG, OMG children showed younger age of disease onset and better outcomes after treatment. No OMG patients progressed to generalized disease during the follow-up period. DISCUSSION Compared with GMG, OMG patients had earlier disease onset and improved outcomes after treatment.
Collapse
Affiliation(s)
| | - Diana Castro
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joan S Reisch
- Division of Biostatistics, Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Susan T Iannaccone
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
18
|
|
19
|
Yan C, Li W, Song J, Feng X, Xi J, Lu J, Zhou S, Zhao C. Cell-Based Versus Enzyme-Linked Immunosorbent Assay for the Detection of Acetylcholine Receptor Antibodies in Chinese Juvenile Myasthenia Gravis. Pediatr Neurol 2019; 98:74-79. [PMID: 31307830 DOI: 10.1016/j.pediatrneurol.2019.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/16/2019] [Accepted: 01/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients in China with juvenile-onset myasthenia gravis present early, with a high prevalence of purely ocular symptoms, spontaneous remission rates, and low antibody seropositivity. Antibody detection using a cell-based assay has been reported to increase the diagnostic sensitivity in adult-onset myasthenia gravis. However, this method in patients with juvenile-onset myasthenia gravis has not been investigated. METHODS Patients with juvenile-onset myasthenia gravis who had not received prednisone or immunosuppressive therapy were recruited between June 2015 and April 2018 at the Huashan Hospital. Clinical information was collected. Serum anti-acetylcholine receptor antibodies were detected via cell-based assay with HEK293T cells expressing acetylcholine receptor subunits and rapsyn. Additionally, the IgG antibody subclass was identified. RESULTS Eighty-two patients with juvenile-onset myasthenia gravis were enrolled in the current study. Among them, 48 patients were anti-acetylcholine receptor positive (58.5%) and 34 were seronegative (41.5%), as assessed via enzyme-linked immunosorbent assay. Cell-based assay yielded 63 positive subjects (76.8%) and 19 seronegative subjects (23.2%). All the enzyme-linked immunosorbent assay-positive samples showed robust immunofluorescence in the cell-based assay, whereas 15 of 34 enzyme-linked immunosorbent assay-negative patients (44.1%) were found to have low-affinity acetylcholine receptor antibodies. Among all the cell-based assay-positive patients, 41 were positive for both adult and fetal acetylcholine receptor antibodies (50.0%), 18 were found positive for only adult acetylcholine receptor antibodies (21.9%), and four were found to possess only fetal acetylcholine receptor antibodies (4.9%). Fifteen antibody-positive samples underwent subclassification and were confirmed to be IgG1 subclass predominant (n = 15, including eight adult and fetal acetylcholine receptor antibody positive, five only adult acetylcholine receptor antibody positive, and two only fetal acetylcholine receptor antibody positive). There were no significant differences in clinical features among patients with different antibody profiles. CONCLUSIONS The cell-based assay showed increased sensitivity in acetylcholine receptor antibody detection in Chinese patients with juvenile-onset myasthenia gravis, and most cases of Chinese juvenile-onset myasthenia gravis are still acetylcholine receptor autoantibody mediated. Furthermore, the antibodies detected are predominately of the IgG1 subclass.
Collapse
Affiliation(s)
- Chong Yan
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenhui Li
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Jie Song
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuelin Feng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Shuizhen Zhou
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China; Department of Neurology, Jing'an District Centre Hospital of Shanghai, Fudan University, Shanghai, China.
| |
Collapse
|
20
|
Abstract
With specialized care, patients with myasthenia gravis can have very good outcomes. The mainstays of treatment are acetylcholinesterase inhibitors, and immunosuppressive and immunomodulatory therapies. There is good evidence thymectomy is beneficial in thymomatous and nonthymomatous disease. Nearly all of the drugs used for MG are considered "off-label." The 2 exceptions are acetylcholinesterase inhibitors and complement inhibition with eculizumab, which was recently approved by the US Food and Drug Administration for myasthenia gravis. This article reviews the evidence base and provides a framework for the treatment of myasthenia gravis, highlighting recent additions to the literature.
Collapse
|
21
|
Chou CC, Su IC, Chou IJ, Lin JJ, Lan SY, Wang YS, Kong SS, Chen YJ, Hsieh MY, Hung PC, Wang HS, Chou ML, Lin KL. Correlation of anti-acetylcholine receptor antibody levels and long-term outcomes of juvenile myasthenia gravis in Taiwan: a case control study. BMC Neurol 2019; 19:170. [PMID: 31319795 PMCID: PMC6637626 DOI: 10.1186/s12883-019-1397-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 07/08/2019] [Indexed: 12/19/2022] Open
Abstract
Background Myasthenia gravis is the most common disease affecting the neuromuscular junction. The most common etiology among patients with juvenile myasthenia gravis is the production of antibodies against the acetylcholine receptor. However, the clinical outcome in relation to serum levels of anti-acetylcholine receptor antibodies in juvenile myasthenia gravis has rarely been discussed. We aimed to analyze the correlation between the presence of anti-acetylcholine receptor antibodies and outcome in juvenile myasthenia gravis. Methods Patients diagnosed with juvenile myasthenia gravis younger than of 20 years of age were retrospectively recruited from January 1995 to February 2017 in a tertiary referral medical center. According to the Myasthenia Gravis Foundation of America outcome scale, the primary outcome was complete symptom remission and cessation of medications for at least 1 year measured 2 years after diagnosis. Secondary outcome was complete symptom remission at the last outpatient clinic. Results A total of 54 patients were followed up for over 2 years. Nine patients (9/54, 16.7%) achieved complete remission without medication use at 2 years after diagnosis. Thirteen (24.1%) patients achieved complete remission during longer follow-up periods. Those with negative anti-acetylcholine receptor antibodies were more likely to achieve complete remission at 2 years (6/15 [40%] vs. 3/39 [7.7%], 95% Confidence interval [CI] 1.670 to 38.323) and at the last outpatient clinic follow-up (8/15 [53.3%] vs. 5/39 [12.8%], 95% CI 2.367 to 20.704). Thirteen patients with comorbid autoimmune thyroid diseases were older than those without disease (11.8 ± 5.8 years old vs. 8.0 ± 6.3 years old, 95% CI 0.018 to 7.33). Moreover, patients negative for anti-acetylcholine receptor antibodies were less likely comorbid with autoimmune thyroid disease (1/35 [2.9%] vs. 12/71 [16.9%], 95% CI 0.018 to 1.161). Conclusions Juvenile myasthenia gravis patients without anti-acetylcholine antibodies exhibited significantly increased complete remission rates and a reduced likelihood of comorbid autoimmune thyroid diseases compared with those with anti-acetylcholine receptor antibodies among Chinese. Electronic supplementary material The online version of this article (10.1186/s12883-019-1397-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Cheng-Che Chou
- Division of Paediatrics, Keelung Chang Gung Memorial Hospital, 222, Maijin Road, Keelung, Taiwan
| | - I-Chen Su
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - I-Jun Chou
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.,Division of Paediatrics, Neurocritical Care Centre, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shih-Yun Lan
- Division of Paediatrics, Saint Paul Hospital, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Yi-Shan Wang
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Shu-Sing Kong
- Division of Paediatrics, Taipei Medical University Shuang Ho Hospital, Zhonghe Dist., New Taipei City, Taiwan
| | - Yun-Ju Chen
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Meng-Ying Hsieh
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Po-Cheng Hung
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Min-Liang Chou
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.
| | - Kuang-Lin Lin
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.
| | | |
Collapse
|
22
|
Abstract
RATIONALE Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction that can be triggered by anticholinergic agents. PATIENT CONCERNS We present a 4-year-old female patient who was admitted to the outpatient clinic. She complained of drooped eyelids, which first appeared 2 days after taking a 200 mg dose of pyrantel pamoate. Past medical history is negative. DIAGNOSES AND TREATMENT She was hospitalized with a diagnosis of ocular type MG, and pyridostigmine (40 mg/day) treatment was started. OUTCOMES The patient recovered, and subsequently, the treatment dose was tapered. CONCLUSION Pyrantel is an antihelminthic that acts as an agonist of nicotinic acetylcholine receptors (AChRs) of nematodes and exerts its therapeutic effects by depolarizing their muscle membranes. Consequently, there may be an association between pyrantel pamoate and MG.
Collapse
|
23
|
Mansukhani SA, Bothun ED, Diehl NN, Mohney BG. Incidence and Ocular Features of Pediatric Myasthenias. Am J Ophthalmol 2019; 200:242-249. [PMID: 30653958 PMCID: PMC6587184 DOI: 10.1016/j.ajo.2019.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 01/05/2019] [Accepted: 01/05/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To report the incidence, demographics, and ocular findings of children with myasthenia. DESIGN Retrospective cohort study. METHODS The medical records of all children (<19 years) examined at Mayo Clinic with any form of myasthenia from January 1 1966, through December 31, 2015, were retrospectively reviewed. RESULTS A total of 364 children were evaluated during the study period, of which 6 children were residents of the Olmsted County at the time of their diagnosis, yielding an annual age- and sex-adjusted incidence of 0.35 per 100 000 <19 years, or 1 in 285 714 <19 years. The incidence of juvenile myasthenia gravis (JMG) and congenital myasthenic syndrome (CMS) was 0.12 and 0.23 per 100 000, respectively. Of the 364 study children, 217 (59.6%) had JMG, 141 (38.7%) had CMS, and 6 (1.7%) had Lambert-Eaton syndrome, diagnosed at a median age of 13.5, 5.1, and 12.6 years, respectively. A majority of the JMG and CMS patients had ocular involvement (90.3% and 85.1%, respectively), including ptosis and ocular movement deficits. Among children with at least 1 year of follow-up (JMG; median, 7.1 years, CMS; median, 7.0 years), improvement was seen in 88.8% of JMG patients (complete remission in 31.3%) and in 58.3% of CMS patients. CONCLUSION Although relatively rare, myasthenia gravis in children has 2 predominant forms, CMS and JMG, both of which commonly have ocular involvement. Improvement is more likely in children with the juvenile form.
Collapse
|
24
|
Juvenile Ocular Myasthenia Gravis: Presentation and Outcome of a Large Cohort. Pediatr Neurol 2018; 87:36-41. [PMID: 30197221 DOI: 10.1016/j.pediatrneurol.2018.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 06/19/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Isolated ocular myasthenia gravis (MG) is sparingly common in children relative to adults, ranging from 71% to 93% of all children with MG. PURPOSE We aimed to characterize the ocular manifestations and outcomes in children with isolated ocular MG. METHODS Medical records of consecutive 62 subjects less than 15 years of age with ocular MG, were retrospectively reviewed. Demographic data, presenting ocular features, types and variabilities of duction limitation, MG confirmatory tests, types of and responses to treatment, and generalized MG conversion were reviewed. RESULTS Mean age at onset and follow-up time were 49 months (range, one to 173 months) and 95 months (range, six to 226 months), respectively. Female-to-male ratio was 1.5:1. Initially, ptosis was found in 60 subjects (96.8%), while duction limitation was observed in 28 subjects (45.2%). Total ophthalmoparesis was the most common type of duction limitation. Variability of duction limitation was found in 68% of subjects during the follow-up. Pyridostigmine alone was the most common medication used (48.4%); ptosis was more responsive to therapy than duction limitation. Conversion to generalized MG occurred in 19.4% of subjects, with a mean interval to conversion of nine months after symptom onset. Most conversions (91.7%) occurred in the first two years. CONCLUSIONS Ptosis was more responsive to treatment than duction limitation. Thus other treatment modalities, as well as strabismic amblyopia screening, should be considered in children with prolonged duction limitation that is refractory to medication. In contrast with adults, a much lower proportion of children converted to generalized MG. This may explain the higher prevalence of isolated ocular MG among the juvenile population.
Collapse
|
25
|
Cea G, Martinez D, Salinas R, Vidal C, Hoffmeister L, Stuardo A. Clinical and epidemiological features of myasthenia gravis in Chilean population. Acta Neurol Scand 2018; 138:338-343. [PMID: 29845611 DOI: 10.1111/ane.12967] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To provide an estimated prevalence and describe the clinical features of myasthenia gravis (MG) in Chile. METHOD We carried out (i) a prevalence study of MG using the capture-recapture method and the hospital register of pyridostigmine prescription in South-East Santiago (ii) a nationwide survey of MG patients. RESULTS Prevalence in adults in South-East Santiago was estimated to be 8.36/100 000 inhabitants (CI: 95%, 7.98-8.80). From the nationwide survey, 405 questionnaires were analysed, there was a female/male ratio of 2.2:1. The mean age of onset of symptoms was 38.7 years (range 1-89). The onset was ocular in 46.4%, oculobulbar in 11.6%, bulbar in 8.9%, limbs in 11.6% and generalized in 21.4%. Of the 13.3% of patients who had had a diagnosis of thymoma, only four of these patients were >60 years old at onset. Thymomas were commoner in patients living in mining counties. Patients ≥60 years old at onset of MG formed 19.5% of the sample, female/male ratio 0.97:1. Associated autoimmune diseases were reported in 14% of patients and in family members of 31.8% of patients. A total of 78 patients had to change work due to MG and 68 needed help in carrying out daily activities. CONCLUSIONS This study reduces the gap in information about MG in South America. The prevalence of MG in Chile is within the range described worldwide. We did not see an increase in male frequency in the older age of onset group and thymoma was more frequent in the fifth and sixth decades.
Collapse
Affiliation(s)
- G. Cea
- Facultad de Medicina; Departamento de Ciencias Neurológicas; Universidad de Chile; Santiago Chile
- Servicio de Neurología; Hospital del Salvador; Santiago Chile
| | | | - R. Salinas
- Facultad de Medicina; Departamento de Ciencias Neurológicas; Universidad de Chile; Santiago Chile
- Servicio de Neurología; Hospital del Salvador; Santiago Chile
| | - C. Vidal
- Escuela de Salud Pública; Universidad Mayor; Santiago Chile
| | - L. Hoffmeister
- Escuela de Salud Pública; Universidad Mayor; Santiago Chile
| | - A. Stuardo
- Servicio de Neurología; Hospital del Salvador; Santiago Chile
| |
Collapse
|
26
|
Alvarez CN, John RM. The Pediatric Primary Care Management of Myasthenia Gravis. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2018.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
27
|
Schlechter AK, Gorn M. Eleven-Year-Old Male With Weakness. Ann Emerg Med 2018; 72:127-155. [PMID: 30031505 DOI: 10.1016/j.annemergmed.2018.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Anna K Schlechter
- Department of Pediatric Emergency Medicine, University of Texas at Austin, Dell Children's Medical Center of Central Texas, Austin, TX
| | - Michael Gorn
- Department of Pediatric Emergency Medicine, University of Texas at Austin, Dell Children's Medical Center of Central Texas, Austin, TX
| |
Collapse
|
28
|
Ogutlu H, Karayagmurlu A, Esin IS, Dursun OB. Myasthenia Gravis Attack after Oral Risperidone Treatment: A Case Report. Eurasian J Med 2018; 50:128-129. [PMID: 30002582 DOI: 10.5152/eurasianjmed.2018.17296] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 12/11/2017] [Indexed: 11/22/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease, which can be triggered by anticholinergic agents. The 6-year-old female patient was admitted to the outpatient clinic. She was had been previously diagnosed with comorbid attention deficit hyperactivity disorder and conduct disorder and was receiving short-acting methylphenidate and risperidone, as recommended by a child psychiatrist. However, after using the drugs, she stated that she was overly tired during the day and that her eyelids drooped. Hence, the current treatment was stopped. She was hospitalized with a prediagnosis of ocular type MG and pyridostigmine (90 mg/day) treatment was started. The patient recovered and subsequently the treatment was stopped. Since psychiatric symptoms of the patient resurfaced, long-acting methylphenidate treatment was initiated. During this treatment, the symptoms of MG did not return. The Naranjo's scale of adverse drug reaction probability was completed. Consequently, there may be an association between risperidone and MG.
Collapse
Affiliation(s)
- Hakan Ogutlu
- Department of Child and Adolescent Psychiatry, Ataturk University School of Medicine Erzurum, Turkey
| | - Ali Karayagmurlu
- Department of Child and Adolescent Psychiatry, Gaziantep Maternity and Child Health Hospital, Gaziantep, Turkey
| | - Ibrahim Selcuk Esin
- Department of Child and Adolescent Psychiatry, Ataturk University School of Medicine Erzurum, Turkey
| | - Onur Burak Dursun
- Department of Child and Adolescent Psychiatry, Ataturk University School of Medicine Erzurum, Turkey
| |
Collapse
|
29
|
Maneh N, Apetse K, Diatewa BM, Domingo SAB, Agba AI, Ayena KD, Balogou KA, Balo KP. [Juvenile myasthenia gravis in sub-Saharan Africa: a case study of two consanguine sisters born from consanguinity in Togo]. Pan Afr Med J 2017; 28:63. [PMID: 29230265 PMCID: PMC5718764 DOI: 10.11604/pamj.2017.28.63.13709] [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: 08/26/2017] [Accepted: 09/12/2017] [Indexed: 11/11/2022] Open
Abstract
La myasthénie est une pathologie auto-immune acquise rare à l'origine de la déficience de la transmission neuro-musculaire dont la forme juvénile se manifeste souvent par une atteinte oculaire exclusive. Nous rapportons deux cas de myasthénie juvénile oculaire (MJO) au sein d'une même fratrie. il s'agit de deux fillettes XA et XB respectivement âgées de 11 et 9 ans d'origine malienne résidant au Togo, issues d'un mariage consanguin de 1er degré, amenées en consultation d'ophtalmologie, pour une baisse progressive de l'acuité visuelle (AV). XA avait aux deux yeux, une AV à 8/10 et XB, une AV de 3/10 améliorée au trou sténopéïque à 7/10 en faveur d'une amétropie. XA présentait un ptosis bilatéral qui remontait à l'âge de 2 ans avec une action du releveur de la paupière supérieure (RPS) à 7 mm et XB, un ptosis bilatéral remontant à l'âge de 3 ans avec une action du RPS nulle. Pour les deux, le test au glaçon était franchement positif, le signe de Cogan présent avec une parésie oculo motrice sans diplopie. Le dosage des auto-anticorps anti récepteurs de l'acéthylcholine était normal. Le diagnostic de MJO associée à une amétropie a été évoqué. Une correction optique de l'amétropie par des lunettes et un traitement spécifique par la pyridostigmine avait été instaurée mais les patientes ont été perdues de vue. la myasthénie auto-immune avec des manifestations ophtalmologiques inaugurales est rare mais possible chez l'enfant en Afrique subsaharienne où des études sont nécessaires pour y déterminer les éventuelles particularités de la maladie.
Collapse
Affiliation(s)
- Nidain Maneh
- Université de Lomé, Faculté des Sciences de la Santé, Lomé, Togo.,Service d'Ophtalmologie, CHU-Campus de Lomé, Lomé, Togo
| | - Kossivi Apetse
- Université de Lomé, Faculté des Sciences de la Santé, Lomé, Togo.,Service de Neurologie, Chu-campus de Lomé, Lomé, Togo
| | | | | | | | | | - Koffi Agnon Balogou
- Université de Lomé, Faculté des Sciences de la Santé, Lomé, Togo.,Service de Neurologie, Chu-campus de Lomé, Lomé, Togo
| | | |
Collapse
|
30
|
Barraud C, Desguerre I, Barnerias C, Gitiaux C, Boulay C, Chabrol B. Clinical features and evolution of juvenile myasthenia gravis in a French cohort. Muscle Nerve 2017; 57:603-609. [PMID: 28877546 DOI: 10.1002/mus.25965] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2017] [Indexed: 01/17/2023]
Abstract
INTRODUCTION In this study we determined the clinical, paraclinical, and treatment-related features of juvenile myasthenia gravis (JMG) as well as the clinical course in a cohort of French children. METHODS We conducted a retrospective study of 40 patients with JMG at 2 French pediatric neurology departments from April 2004 to April 2014. RESULTS Among the patients, 70% had generalized JMG, 52% had positive acetylcholine receptor antibodies, 8% had muscle-specific kinase antibodies, and 40% were seronegative. Treatment with acetylcholinesterase inhibitors was effective and sufficient in 47% of patients. The 6 patients with generalized JMG treated with rituximab and/or immunoadsorption showed improvement. Thirty percent of the patients required hospitalization in an intensive care unit during follow-up (mean 4.7 years). Remission without treatment occurred in 18% of patients. DISCUSSION As with adults, JMG has high morbidity, particularly among children with generalized symptoms, and rituximab should be considered early in the course of the disease as a second-line treatment. Muscle Nerve 57: 603-609, 2018.
Collapse
Affiliation(s)
- Coline Barraud
- APHM Service de Neuropédiatrie, Hôpital La Timone-Enfants, 264, Rue St Pierre Marseille, 13385, cedex 5, France
- Aix-Marseille Université, Marseille, France
| | - Isabelle Desguerre
- APHP Service de Neuropédiatrie, Hôpital Necker-Enfants Malades, Paris, France
- Université René Descartes, Paris, France
| | - Christine Barnerias
- APHP Service de Neuropédiatrie, Hôpital Necker-Enfants Malades, Paris, France
| | - Cyril Gitiaux
- Aix-Marseille Université, Marseille, France
- APHP Service de Neuropédiatrie, Hôpital Necker-Enfants Malades, Paris, France
| | - Christophe Boulay
- APHM Service de Neuropédiatrie, Hôpital La Timone-Enfants, 264, Rue St Pierre Marseille, 13385, cedex 5, France
- Aix-Marseille Université, Marseille, France
| | - Brigitte Chabrol
- APHM Service de Neuropédiatrie, Hôpital La Timone-Enfants, 264, Rue St Pierre Marseille, 13385, cedex 5, France
- Aix-Marseille Université, Marseille, France
| |
Collapse
|
31
|
Popperud TH, Boldingh MI, Rasmussen M, Kerty E. Juvenile myasthenia gravis in Norway: Clinical characteristics, treatment, and long-term outcome in a nationwide population-based cohort. Eur J Paediatr Neurol 2017; 21:707-714. [PMID: 28457757 DOI: 10.1016/j.ejpn.2017.04.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 03/29/2017] [Accepted: 04/10/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND This study aimed to characterize juvenile myasthenia gravis in a national population-based cohort in Norway, and to evaluate long-term outcome and potential differences correlated with prepubertal versus postpubertal disease onset. PATIENTS AND METHODS Patients with onset of myasthenia gravis aged ≤18 years were identified through multiple strategies. Retrospective clinical data were collected by means of medical charts. All patients had an updated clinical examination. Cases were divided into prepubertal and postpubertal onset using age 12 years as the cut off. RESULTS In total, 75 patients were identified of whom 63 were included in the study: 21 in the prepubertal and 42 in the postpubertal onset group. There was a female preponderance in both groups. In total, 59% presented with ocular symptoms, but the great majority of patients in both groups generalized during the two first years of the disease. Myasthenic crisis was more frequent in the prepubertal onset group. All patients were initially treated with pyridostigmine, 26 with steroids, and 17 with other immunosuppressive treatment. The postpubertal cases were more often treated with immunosuppressive therapy. Fifty patients (79%) underwent thymectomy. The general outcome was favourable: 57% became asymptomatic and only four subjects failed to attain clinical improvement. One-third had at least one additional autoimmune disease. CONCLUSION Despite frequent symptom generalization and a subgroup of prepubertal onset with severe disease, the long-term outcome was good, especially in the thymectomized prepubertal onset group. Polyautoimmunity occurred in both groups in one-third.
Collapse
Affiliation(s)
- T H Popperud
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Unit for Hereditary and Inborn Neuromuscular Disorders, Department of Neurology, Oslo University Hospital, Oslo, Norway.
| | - M I Boldingh
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - M Rasmussen
- Unit for Hereditary and Inborn Neuromuscular Disorders, Department of Neurology, Oslo University Hospital, Oslo, Norway; Department of Clinical Neuroscience for Children, Section for Child Neurology, Oslo University Hospital, Oslo, Norway
| | - E Kerty
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
32
|
Sithambaram S, Tripathi N, Gopal-Kothandapani JS, Mordekar S. A 7-year-old boy with dysphagia and proximal muscle weakness. Paediatr Child Health 2017; 22:247-248. [PMID: 29479227 PMCID: PMC5804908 DOI: 10.1093/pch/pxx088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Affiliation(s)
- Sivagamy Sithambaram
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Paediatrics, Doncaster and Bassetlaw Hospitals NHS Trust, Doncaster, UK
| | - Neeta Tripathi
- Department of Paediatrics, Doncaster and Bassetlaw Hospitals NHS Trust,Worksop, UK
| | - Jaya Sujatha Gopal-Kothandapani
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Paediatrics, Doncaster and Bassetlaw Hospitals NHS Trust, Worksop, UK
| | - Santosh Mordekar
- Department of Paediatric Neurology, Sheffield Children's Hospital, Sheffield, UK
| |
Collapse
|
33
|
The role of thymectomy in the treatment of juvenile myasthenia gravis: a systematic review. Pediatr Surg Int 2017; 33:683-694. [PMID: 28401300 DOI: 10.1007/s00383-017-4086-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The role of thymectomy in the treatment of juvenile myasthenia gravis (JMG) is poorly defined. The objective of this systematic review was to evaluate the effect of thymectomy on survival, disease severity, and peri-operative complications for patients with JMG. METHODS A search of MEDLINE, EMBASE, and the Cochrane Library (1/1/2000-3/1/2016) identified all English language, human studies of thymectomy for JMG. The population was patients with JMG age ≤18 years who underwent thymectomy (comparator group was unexposed to thymectomy). Outcomes included survival, disease severity, and post-operative complications. Data extraction was performed by independent reviewers. RESULTS Sixteen retrospective studies included 1131 participants with JMG and 488 (43%) underwent thymectomy. Post-operative improvement in JMG severity occurred for 77% (n = 376/488). Comparisons of thymectomy to non-operative management were mixed. Post-operative complications were poorly recorded. Power to compare surgical approaches was limited. Outcomes specific to antibodies, surgical pathology findings, severity of JMG, and timing of thymectomy were sparse. CONCLUSIONS Existing data regarding thymectomy for JMG are limited and entirely retrospective. The majority of patients who underwent thymectomy had improvement in disease severity and post-operative complications were rare. Prospective, multicenter study of thymectomy for JMG is warranted.
Collapse
|
34
|
Abstract
Myasthenia gravis is a disorder of neuromuscular transmission that leads to fatigue of skeletal muscles and fluctuating weakness. Myasthenia that affects children can be classified into the following 3 forms: transient neonatal myasthenia, congenital myasthenic syndromes, and juvenile myasthenia gravis (JMG). JMG is an autoimmune disorder that has a tendency to affect the extraocular muscles, but can also affect all skeletal muscles leading to generalized weakness and fatigability. Respiratory muscles may be involved leading to respiratory failure requiring ventilator support. Diagnosis should be suspected clinically, and confirmatory diagnostic testing be performed, including serum acetylcholine receptor antibodies, repetitive nerve stimulation, and electromyography. Treatment for JMG includes acetylcholinesterase inhibitors, immunosuppressive medications, plasma exchange, intravenous immunoglobulins, and thymectomy. Children with myasthenia gravis require monitoring by a pediatric ophthalmologist for the development of amblyopia from ptosis or strabismus.
Collapse
|
35
|
Alam MS, Devi Nivean P. Early onset bilateral juvenile myasthenia gravis masquerading as simple congenital ptosis. GMS OPHTHALMOLOGY CASES 2017; 7:Doc07. [PMID: 28293536 PMCID: PMC5343208 DOI: 10.3205/oc000058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Myasthenia gravis is an autoimmune disorder affecting the neuromuscular junction. Ocular myasthenia gravis presents as ptosis with extraocular motility restriction and is prone to be misdiagnosed as third nerve palsy or congenital or aponeurotic ptosis. Juvenile ocular myasthenia gravis in very young children is difficult to diagnose and can be easily labeled as a case of congenital ptosis, the more so when the condition is bilateral. We present a case of a two-year-old child who presented with bilateral ptosis and was diagnosed as a case of simple congenital ptosis elsewhere with the advice to undergo tarsofrontalis sling surgery. The child was diagnosed with juvenile myasthenia gravis on thorough history, examination, and systemic evaluation and was started on anti-myasthenic treatment.
Collapse
Affiliation(s)
- Md Shahid Alam
- Department of Orbit, Oculoplasty, Reconstructive and Aesthetic services, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India
| | | |
Collapse
|
36
|
Popperud TH, Boldingh MI, Brunborg C, Faiz KW, Heldal AT, Maniaol AH, Müller KI, Rasmussen M, Øymar K, Kerty E. Juvenile myasthenia gravis in Norway: A nationwide epidemiological study. Eur J Paediatr Neurol 2017; 21:312-317. [PMID: 27666466 DOI: 10.1016/j.ejpn.2016.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/17/2016] [Accepted: 09/03/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The aim of this study was to assess the incidence rate and prevalence of autoimmune myasthenia gravis (MG) among children in Norway. METHODS This retrospective population-based study was performed in Norway from January 2012 to December 2013. Cases of juvenile MG (JMG) with onset < 18 years were identified through searches in coding systems of electronic patient records at the 15 main hospitals in Norway from 1989 to 2013. In addition, the acetylcholine receptor antibody database at Haukeland University Hospital and the clinical nationwide MG database at Oslo University Hospital were searched for cases of JMG. Diagnosis and age at onset were verified through medical records. Incidence and prevalence rates were calculated using the Norwegian population as reference. RESULTS In total 63 unique JMG cases were identified. This corresponds to an average annual incidence rate of 1.6 per million. Incidence rate was stable over the study period. Prevalence of JMG was 3.6-13.8 per million. Females constituted the majority of JMG cases (55 vs 8 males). The risk of JMG was higher among females both in the postpubertal and prepubertal group (p < 0.001 and p = 0.02, respectively). CONCLUSION This study confirms the rarity of JMG in Norway, especially among males, and shows a stable incidence rate over the last 25 years.
Collapse
Affiliation(s)
- T H Popperud
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - M I Boldingh
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - C Brunborg
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - K W Faiz
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - A T Heldal
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - A H Maniaol
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - K I Müller
- Department of Neurology and National Neuromuscular Centre, University Hospital of North Norway, Tromsø, Norway; Department of Clinical Medicine, UiT - The Artic University of Norway, Tromsø, Norway
| | - M Rasmussen
- Department of Clinical Neuroscience for Children, Section for Child Neurology, Oslo University Hospital, Oslo, Norway; Unit for Hereditary and Inborn Neuromuscular Disorders, Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - K Øymar
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Pediatrics, Stavanger University Hospital, Stavanger, Norway
| | - E Kerty
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
37
|
Affiliation(s)
- Nils E Gilhus
- From the Department of Clinical Medicine, University of Bergen, and the Department of Neurology, Haukeland University Hospital - both in Bergen, Norway
| |
Collapse
|
38
|
Pitt MC, Mchugh JC, Deeb J, Smith RA. Assessing neuromuscular junction stability from stimulated EMG in children. Clin Neurophysiol 2016; 128:290-296. [PMID: 28042994 DOI: 10.1016/j.clinph.2016.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/28/2016] [Accepted: 11/16/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We present our 9-year experience of stimulated EMG potential analysis using concentric electrodes (SPACE) to evaluate neuromuscular junction (NMJ) disorders in awake children. The technique uses high frequency filtration of stimulated motor unit potentials and applies peak detection software to estimate mean consecutive difference (MCD). METHODS SPACE was carried out in orbicularis oculi of 878 children (377 girls; median age 47months) between 2007 and 2015, stimulating the facial nerve with a monopolar cathode. Mean MCD-index (MCD-I) was expressed as a ratio of the measured MCD to the upper normal limit. Diagnostic accuracy was calculated for primary NMJ disorders based on the 660 cases with clinical follow-up data. RESULTS Primary NMJ disorders were present in 106 children, including 46 with genetically confirmed congenital myasthenic syndrome (CMS). Mean MCD-I was two times higher in children with primary NMJ disorders compared to others (205±108μs vs 94±38μs, p<0.005). After excluding children with neuronopathies, an MCD-I >100% had 84% sensitivity and 74% specificity for the primary NMJ disorders. Receiver operating characteristics (ROC) curve identified an MCD-I >115% as providing best diagnostic accuracy with sensitivity of 77% and specificity of 84%. CONCLUSION SPACE is practicable and safe in unsedated children. SIGNIFICANCE In combination with routine EMG, it has high diagnostic accuracy and can facilitate recognition of paediatric NMJ transmission disorders.
Collapse
Affiliation(s)
- Matthew C Pitt
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, United Kingdom.
| | - John C Mchugh
- Department of Clinical Neurophysiology, Our Lady's Children's Hospital, Crumlin, Dublin 12, Ireland
| | - Jacquie Deeb
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, United Kingdom; Department of Clinical Neurophysiology, Queen's Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom
| | - Ralph A Smith
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, United Kingdom
| |
Collapse
|
39
|
Gilhus NE, Verschuuren JJ. Myasthenia gravis: subgroup classifications - Authors' reply. Lancet Neurol 2016; 15:357-8. [PMID: 26971656 DOI: 10.1016/s1474-4422(16)00035-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 01/21/2016] [Accepted: 01/21/2016] [Indexed: 01/23/2023]
Affiliation(s)
- Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, N-5020 Bergen, Norway; Department of Neurology, Haukeland University Hospital, Bergen, Norway.
| | - Jan J Verschuuren
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
40
|
Myasthenia gravis — autoantibody characteristics and their implications for therapy. Nat Rev Neurol 2016; 12:259-68. [DOI: 10.1038/nrneurol.2016.44] [Citation(s) in RCA: 209] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
41
|
van den Engel-Hoek L, de Groot IJM, de Swart BJM, Erasmus CE. Feeding and Swallowing Disorders in Pediatric Neuromuscular Diseases: An Overview. J Neuromuscul Dis 2015; 2:357-369. [PMID: 27858755 PMCID: PMC5240596 DOI: 10.3233/jnd-150122] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Feeding and swallowing problems in infants and children have a great impact on health and wellbeing. The aim of this study was to provide an overview of recognized feeding and swallowing problems in different groups of children with neuromuscular diseases, based on relevant literature and expert opinion, and to propose recommendations for the assessment and treatment of these problems. Almost all pediatric neuromuscular diseases are accompanied by feeding and swallowing problems during the different phases of deglutition, problems that give rise to a wide variety of signs and symptoms, which emphasizes the importance of a comprehensive feeding and swallowing assessment by a speech and language therapist.
Collapse
Affiliation(s)
- Lenie van den Engel-Hoek
- Donders Centre for Neuroscience, Department of Rehabilitation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Imelda J M de Groot
- Donders Centre for Neuroscience, Department of Rehabilitation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bert J M de Swart
- Donders Centre for Neuroscience, Department of Rehabilitation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Corrie E Erasmus
- Donders Centre for Neuroscience, Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
42
|
Sampath S, McCann LJ, McDonagh J, Cleary G, Spinty S, Pain CE, Baildam EM, Beresford MW. Co-existence of juvenile-onset systemic lupus erythematosus and juvenile myasthenia gravis. Lupus 2015; 24:1462-3. [DOI: 10.1177/0961203315591030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 05/18/2015] [Indexed: 11/16/2022]
Affiliation(s)
- S Sampath
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, UK
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, UK
| | - L J McCann
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, UK
| | - J McDonagh
- Department of Paediatric and Adolescent Rheumatology, Birmingham Children’s Hospital NHS Foundation Trust, UK
| | - G Cleary
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, UK
| | - S Spinty
- Department of Paediatric Neurology, Alder Hey Children’s NHS Foundation Trust, UK
| | - C E Pain
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, UK
| | - E M Baildam
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, UK
| | - M W Beresford
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, UK
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, UK
| |
Collapse
|
43
|
Myasthenia gravis: subgroup classification and therapeutic strategies. Lancet Neurol 2015; 14:1023-36. [DOI: 10.1016/s1474-4422(15)00145-3] [Citation(s) in RCA: 563] [Impact Index Per Article: 62.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 06/02/2015] [Accepted: 06/19/2015] [Indexed: 12/13/2022]
|
44
|
Golnik KC. Neuro-Ophthalmology Annual Review. Asia Pac J Ophthalmol (Phila) 2015; 4:307-15. [PMID: 26417928 DOI: 10.1097/apo.0000000000000147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The purpose of this review was to update the practicing ophthalmologist on the English language neuro-ophthalmology literature from the past year. DESIGN A review of English language literature from August 1, 2013, to August 1, 2014, was conducted. METHODS The author searched PubMed from August 1, 2013, to August 1, 2014, limited to English language publications including original articles, review articles, and case reports and excluding letters to the editor, unpublished work, and abstracts. The following topics were searched: pupillary abnormalities, eye movement dysfunction, neuromuscular diseases, optic neuropathies, optic neuritis, demyelinating diseases including multiple sclerosis, lesions of the optic chiasm and posterior primary visual pathways, elevated intracranial pressure, tumors and aneurysms affecting the visual pathways, vascular diseases, higher visual function, and neuroimaging advances. The focus of this review is on clinically relevant literature in the past year for the practicing ophthalmologist. The aim was to highlight remarkable and interesting literature rather than exhaustively including all new neuro-ophthalmological publications of the year. RESULTS Initially, more than 11,000 articles were identified. One hundred were selected that met criteria specified above. CONCLUSIONS This review updates the comprehensive ophthalmologist on neuro-ophthalmic topics.
Collapse
Affiliation(s)
- Karl C Golnik
- From the Department of Ophthalmology, University of Cincinnati and the Cincinnati Eye Institute, Cincinnati, OH
| |
Collapse
|
45
|
Associated morbidity of pediatric ptosis — a large, community based case–control study. Graefes Arch Clin Exp Ophthalmol 2014; 252:1509-14. [DOI: 10.1007/s00417-014-2759-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 07/22/2014] [Indexed: 11/25/2022] Open
|