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Noubani LH, Hummel LA, Pakravan M, Charoenkijkajorn C, Mortensen PW, Lee AG. Delayed Diagnosis of Thymoma in Ocular Myasthenia Gravis. J Neuroophthalmol 2024; 44:e419-e420. [PMID: 39164902 DOI: 10.1097/wno.0000000000001846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024]
Affiliation(s)
- Lema H Noubani
- Texas A and M College of Medicine (LN, AGL), Bryan, Texas; Department of Ophthalmology (LH, AGL), University of Texas Medical Branch, Galveston, Texas; Department of Ophthalmology (MP, CC, PWM, AGL), Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas; Departments of Ophthalmology, Neurology, and Neurosurgery (AGL), Weill Cornell Medicine, New York, New York; University of Texas MD Anderson Cancer Center (AGL), Houston, Texas; and Department of Ophthalmology (AGL), The University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Behbehani R. Ocular Myasthenia Gravis: A Current Overview. Eye Brain 2023; 15:1-13. [PMID: 36778719 PMCID: PMC9911903 DOI: 10.2147/eb.s389629] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
Ocular myasthenia gravis (OMG) is a neuromuscular disease characterized by autoantibody production against post-synaptic proteins in the neuromuscular junction. The pathophysiological auto-immune mechanisms of myasthenia are diverse, and this is governed primarily by the type of autoantibody production. The diagnosis of OMG relies mainly on clinical assessment, the use of serological antibody assays for acetylcholine receptors (AchR), muscle-specific tyrosine kinase (MusK), and low-density lipoprotein 4 (LPR4). Other autoantibodies against post-synaptic proteins, such as cortactin and agrin, have been detected; however, their diagnostic value and pathogenic effect are not yet clearly defined. Clinical tests such as the ice test and electrophysiologic tests, particularly single-fiber electromyography, have a valuable role in diagnosis. The treatment of OMG is primarily through cholinesterase inhibitors (pyridostigmine), and steroids are frequently required in cases of ophthalmoplegia. Other immunosuppressive therapies include antimetabolites (azathioprine, mycophenolate mofetil, methotrexate) and biological agents such as B-cell depleting agents (Rituximab) and complement inhibitors (eculizumab). Evidence is scarce on the effect of immunosuppressive therapy on altering the natural course of OMG. Clinicians must be vigilant of a myasthenic syndrome in patients using immune-check inhibitors. Reliable and consistent biomarkers are required to assess disease severity and response to therapy to optimize the management of OMG. The purpose of this review is to summarize the current trends and the latest developments in diagnosing and treating OMG.
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Affiliation(s)
- Raed Behbehani
- Neuroophthalmology Unit, Ibn Sina Hospital, Kuwait City, Kuwait,Correspondence: Raed Behbehani, Ibn Sina Hospital, P.O Box 1180, Tel +965 2224 2999, Fax +965 2249 2406, Email
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Chen K, Li Y, Yang H. Poor responses and adverse outcomes of myasthenia gravis after thymectomy: Predicting factors and immunological implications. J Autoimmun 2022; 132:102895. [PMID: 36041292 DOI: 10.1016/j.jaut.2022.102895] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
Abstract
Myasthenia gravis (MG) has been recognized as a series of heterogeneous but treatable autoimmune conditions. As one of the indispensable therapies, thymectomy can achieve favorable prognosis especially in early-onset generalized MG patients with seropositive acetylcholine receptor antibody. However, poor outcomes, including worsening or relapse of MG, postoperative myasthenic crisis and even post-thymectomy MG, are also observed in certain scenarios. The responses to thymectomy may be associated with the general characteristics of patients, disease conditions of MG, autoantibody profiles, native or ectopic thymic pathologies, surgical-related factors, pharmacotherapy and other adjuvant modalities, and the presence of comorbidities and complications. However, in addition to these variations among individuals, pathological remnants and the abnormal immunological milieu and responses potentially represent major mechanisms that underlie the detrimental neurological outcomes after thymectomy. We underscore these plausible risk factors and discuss the immunological implications therein, which may be conducive to better managing the indications for thymectomy, to avoiding modifiable risk factors of poor responses and adverse outcomes, and to developing post-thymectomy preventive and therapeutic strategies for MG.
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Affiliation(s)
- Kangzhi Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.
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Zhang J, Zhang Z, Zhang H, Cui Y, Chen Y, Lv P, Zhang P. Thymectomy in ocular myasthenia gravis-prognosis and risk factors analysis. Orphanet J Rare Dis 2022; 17:309. [PMID: 35945595 PMCID: PMC9361517 DOI: 10.1186/s13023-022-02454-y] [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: 03/07/2022] [Accepted: 07/17/2022] [Indexed: 11/12/2022] Open
Abstract
Background Several retrospective studies have identified risk factors associated with ocular myasthenia gravis (OMG) generalization in non-surgical patients. However, the outcomes of OMG after thymectomy have not been investigated fully. This study aimed to explore the clinical predictors of post-thymectomy OMG prognosis. Methods We performed a retrospective review of OMG patients who underwent thymectomy at our institution from January 2012 to December 2021. Kaplan–Meier and Cox proportional hazard regression analyses were used to evaluate associations between clinical features and prognosis. The main outcome measures were OMG conversion, complete stable remission (CSR), and clinical improvement. Results Fifty-eight patients were identified for conversion analysis. Thirteen (22.4%) developed generalized myasthenia gravis (GMG) at a median time of 12.7 (3–37.3) months from symptom onset. Repetitive nerve stimulation (RNS)-positivity was associated with increased risk of conversion to GMG (P = 0.002). Patients with histotype B2/B3 thymoma showed a higher risk of conversion (P = 0.002) than did patients with hyperplasia and AB/B1 thymoma. Fifty-two patients fulfilled the criteria for CSR and improvement. Sixteen (30.8%) achieved CSR at a median time of 28.7 (15–54) months after thymectomy. Fifteen (28.8%) showed clinical improvement at last follow up. Patients who achieved CSR showed a younger age of onset (P = 0.022), lower percentage of acetylcholine receptor antibody-seropositivity (P = 0.029). Histologically, patients with thymic hyperplasia and stage I thymoma showed a higher chance of CSR (P = 0.010) than did patients with stage II/III thymoma. Multivariate analysis revealed that RNS-positivity (hazard ratio [HR] 6.007, P = 0.021) and histotype B2/B3 thymoma (HR 4.611, P = 0.048) were associated with OMG conversion. Thymic hyperplasia and stage I thymoma (HR 0.300, P = 0.026) were associated with OMG CSR after thymectomy. Conclusion For OMG patients after thymectomy, RNS-positivity and histotype B2/B3 thymoma are independent predictors of conversion to GMG. On the other hand, thymic hyperplasia and stage I thymoma independently predict CSR.
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Affiliation(s)
- Jinwei Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Zeyang Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Hui Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Yuantao Cui
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Yuan Chen
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Peng Lv
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Peng Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China.
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Forgash JT, Chang YM, Mittelman NS, Petesch S, Benedicenti L, Galban E, Hammond JJ, Glass EN, Barker JR, Shelton GD, Luo J, Garden OA. Clinical features and outcome of acquired myasthenia gravis in 94 dogs. J Vet Intern Med 2021; 35:2315-2326. [PMID: 34331481 PMCID: PMC8478050 DOI: 10.1111/jvim.16223] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 06/25/2021] [Accepted: 07/12/2021] [Indexed: 12/22/2022] Open
Abstract
Background Factors known to be associated with outcome of acquired myasthenia gravis (MG) in dogs are limited. Hypothesis/Objectives Of dogs with MG, advancing age and comorbid neoplasia are associated with poor long‐term prognosis and low rates of remission. Animals Ninety‐four client‐owned dogs with MG diagnosed by acetylcholine receptor antibody (AChR Ab) assay between 2001 and 2019 from a university clinic and 3 private clinics in the United States. Methods Cases were retrospectively evaluated and data were collected to determine clinical signs, treatment, and response to therapy defined by means of a clinical scoring rubric. Immunological remission was defined as a return of the AChR Ab concentration to <0.6 nmol/L. Multivariable binary logistic regression analysis was used to identify clinical criteria predicting remission. Results An anticholinesterase drug was used to treat 90/94 (96%) dogs, which in 63/94 (67%) was the sole treatment; other drugs included immune modulators. Clinical remission (lack of clinical signs ≥4 weeks after treatment cessation) was observed in 29 (31% [95% confidence interval (CI): 22.4‐40.8%]) dogs, clinical response (lack of clinical signs on treatment) in 14 (15% [95% CI: 9.0‐23.6%]) dogs, clinical improvement (on treatment) in 24 (26% [95% CI: 17.8‐35.2%]) dogs, and no clinical improvement in 27 (29% [95% CI: 20.5‐38.6%]) dogs. Immunological remission was observed in 27/46 (59%) dogs, with clinical remission in all 27. Younger age (P = .04) and comorbid endocrine disease (P = .04) were associated with clinical remission. Initial AChR Ab concentration (P = .02) and regurgitation (P = .04) were negatively associated with clinical remission. Conclusions and Clinical Importance Clinical remission in MG is less likely in older dogs and dogs presenting with regurgitation or high initial AChR Ab concentration, but more likely in younger dogs and dogs with comorbid endocrine disease.
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Affiliation(s)
- Jennifer T Forgash
- Department of Clinical Sciences & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yu-Mei Chang
- Research Support Office, Royal Veterinary College, University of London, London, United Kingdom
| | - Neil S Mittelman
- Department of Clinical Sciences & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott Petesch
- Department of Clinical Sciences & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leontine Benedicenti
- Department of Clinical Sciences & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Evelyn Galban
- Department of Clinical Sciences & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James J Hammond
- Department of Neurology and Neurosurgery, Pieper Memorial Veterinary Center, Middletown, Connecticut, USA
| | - Eric N Glass
- Section of Neurology and Neurosurgery, Red Bank Veterinary Hospital, Tinton Falls, New Jersey, USA
| | - Jessica R Barker
- Department of Neurology and Neurosurgery, Bush Veterinary Neurology Service, Springfield, Virginia, USA
| | - G Diane Shelton
- Department of Pathology, School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Jie Luo
- Department of Clinical Sciences & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Oliver A Garden
- Department of Clinical Sciences & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Menghesha H, Schroeter M, Doerr F, Schlachtenberger G, Heldwein MB, Chiapponi C, Wahlers T, Bruns C, Hekmat K. [The value of thymectomy in the treatment of non-thymomatous myasthenia gravis]. Chirurg 2021; 93:48-55. [PMID: 34132824 PMCID: PMC8766382 DOI: 10.1007/s00104-021-01436-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2021] [Indexed: 11/26/2022]
Abstract
The value of thymectomy in the treatment of non-thymomatous myasthenia gravis has been controversially discussed. The relatively low incidence and prevalence of this disease, the inconsistent documentation in various studies and the necessity of a long-term follow-up to assess the therapeutic effects has made the generation of valid data difficult. The publication in 2016 of the MGTX trial in the New England Journal of Medicine delivered the first randomized controlled data in which patients aged 18-65 years with generalized myasthenia gravis and positive for acetylcholine receptor antibodies showed a significant benefit after surgical resection of the thymus via median sternotomy. Despite a lack of validation of the advantages of thymectomy by minimally invasive surgery from randomized controlled studies, this technique seems to positively influence the outcome of certain patient groups in a similar way. Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS) using subxyphoidal and transcervical access routes showed not only esthetic advantages but also showed no relevant inferiority in the influence on clinical outcomes of myasthenia gravis compared to median sternotomy; however, not only the benefits and the esthetic results show differences but also the advantages in the various subtypes of myasthenia gravis show divergent prospects of success with respect to remission. The clinical spectrum of myasthenia is heterogeneous with respect to the occurrence of antibodies, the body region affected and the age of the patient at first diagnosis. Ultimately, thymectomy is an effective causal treatment of myasthenia gravis.
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Affiliation(s)
- Hruy Menghesha
- Klinik und Poliklinik für Herzchirurgie, herzchirurgische Intensivmedizin und Thoraxchirurgie, Universitätsklinik Köln, Universität zu Köln, Kerpener Straße 62, 50931, Köln, Deutschland.
| | - Michael Schroeter
- Klinik und Poliklinik für Neurologie, Universitätsklinik Köln, Universität zu Köln, Köln, Deutschland
| | - Fabian Doerr
- Klinik und Poliklinik für Herzchirurgie, herzchirurgische Intensivmedizin und Thoraxchirurgie, Universitätsklinik Köln, Universität zu Köln, Kerpener Straße 62, 50931, Köln, Deutschland
| | - Georg Schlachtenberger
- Klinik und Poliklinik für Herzchirurgie, herzchirurgische Intensivmedizin und Thoraxchirurgie, Universitätsklinik Köln, Universität zu Köln, Kerpener Straße 62, 50931, Köln, Deutschland
| | - Matthias B Heldwein
- Klinik und Poliklinik für Herzchirurgie, herzchirurgische Intensivmedizin und Thoraxchirurgie, Universitätsklinik Köln, Universität zu Köln, Kerpener Straße 62, 50931, Köln, Deutschland
| | - Costanza Chiapponi
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Tumor-, und Transplantationschirurgie, Universitätsklinik Köln, Universität zu Köln, Köln, Deutschland
| | - Thorsten Wahlers
- Klinik und Poliklinik für Herzchirurgie, herzchirurgische Intensivmedizin und Thoraxchirurgie, Universitätsklinik Köln, Universität zu Köln, Kerpener Straße 62, 50931, Köln, Deutschland
| | - Christiane Bruns
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Tumor-, und Transplantationschirurgie, Universitätsklinik Köln, Universität zu Köln, Köln, Deutschland
| | - Khosro Hekmat
- Klinik und Poliklinik für Herzchirurgie, herzchirurgische Intensivmedizin und Thoraxchirurgie, Universitätsklinik Köln, Universität zu Köln, Kerpener Straße 62, 50931, Köln, Deutschland
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Frykman H, Kumar P, Oger J. Immunopathology of Autoimmune Myasthenia Gravis: Implications for Improved Testing Algorithms and Treatment Strategies. Front Neurol 2020; 11:596621. [PMID: 33362698 PMCID: PMC7755715 DOI: 10.3389/fneur.2020.596621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/19/2020] [Indexed: 12/13/2022] Open
Abstract
Myasthenia gravis (MG) is a heterogeneous condition, characterized by autoantibodies (Abs) that target functionally important structures within neuromuscular junctions (NMJ), thus affecting nerve-to-muscle transmission. MG patients are more often now subgrouped based on the profile of serum autoantibodies, which segregate with clinical presentation, immunopathology, and their response to therapies. The serological testing plays an essential role in confirming MG diagnosis and guiding disease management, although a small percentage of MG patients remain negative for antibodies. With the advancements in new highly effective pathophysiologically-specific immunotherapeutic options, it has become increasingly important to identify the specific Abs responsible for the pathogenicity in individual MG patients. There are several new assays and protocols being developed for the improved detection of Abs in MG patients. This review focuses on the divergent immunopathological mechanisms in MG, and discusses their relevance to improved diagnostic and treatment. We propose a comprehensive "reflex testing," algorithm for the presence of MG autoantibodies, and foresee that in the near future, the convenience and specificity of novel assays will permit the clinicians to consider them into routine systematic testing, thus stimulating laboratories to make these tests available. Moreover, adopting treatment driven testing algorithms will be crucial to identify subgroups of patients potentially benefiting from novel immunotherapies for MG.
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Affiliation(s)
- Hans Frykman
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Neuroimmunology Lab, University of British Columbia, Vancouver, BC, Canada
| | - Pankaj Kumar
- BC Neuroimmunology Lab, University of British Columbia, Vancouver, BC, Canada
| | - Joel Oger
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Neuroimmunology Lab, University of British Columbia, Vancouver, BC, Canada
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