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Maycock TJ, Rossor T, Vanegas M, Gringras P, Jungbluth H. Child Neurology: Common Occurrence of Narcolepsy Type 1 and Myasthenia Gravis. Neurology 2024; 103:e209598. [PMID: 38976840 DOI: 10.1212/wnl.0000000000209598] [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: 07/10/2024] Open
Abstract
Narcolepsy with cataplexy and myasthenia gravis are both chronic neurologic conditions causing symptoms of muscle weakness, often affecting facial muscles, and have both been attributed to an immune-mediated etiology. We report an adolescent girl diagnosed with both conditions and discuss possible shared mechanisms and the diagnostic challenges presented by her case to inform and aid clinicians managing children and young people with these rare conditions.
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Di Stefano V, Iacono S, Militello M, Leone O, Rispoli MG, Ferri L, Ajdinaj P, Lanza P, Lupica A, Crescimanno G, Monastero R, Di Muzio A, Brighina F. Comorbidity in myasthenia gravis: multicentric, hospital-based, and controlled study of 178 Italian patients. Neurol Sci 2024; 45:3481-3494. [PMID: 38383750 PMCID: PMC11176220 DOI: 10.1007/s10072-024-07368-0] [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: 09/30/2023] [Accepted: 01/27/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disorder with fluctuating weakness that causes significant disability and morbidity. Comorbidities may influence the course of MG, particularly in specific subgroups. The aim of this study is to investigate the frequency of comorbidities in MG patients compared to healthy controls (HC) and to evaluate their distribution according to age at disease onset, sex, and disease severity. METHODS MG patients attending the University Hospital "Paolo Giaccone" in Palermo and "SS Annunziata" Hospital in Chieti were enrolled; HC were enrolled from the general population. Non-parametric statistics and logistic regression were used to assess the association of specific comorbidities according to age at disease onset, sex, disease subtypes, and severity of the disease. RESULTS A total of 356 subjects were included in the study: 178 MG patients (46% F; median age 60 years [51-71]) and 178 sex- and age-matched HC (46% F, median age 59 years [50-66]). Overall, 86% of MG patients and 76% of HC suffered from comorbidities, and MG patients had a higher number of comorbidities compared to HC. Patients with late-onset suffered from more comorbidities than those with early-onset MG. Hypertension was more common in male patients with MG, while thymic hyperplasia, osteoporosis, and autoimmune diseases were more common in females. Respiratory disorders and thymoma were more common in patients with more severe disease (p < 0.05 for all comparisons). CONCLUSION MG patients, particularly those with late onset, showed a higher prevalence of comorbidities than HC. Assessment of comorbidities in MG is an essential issue to identify the appropriate treatment and achieve the best management.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Salvatore Iacono
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Massimiliano Militello
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Olga Leone
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | | | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Paola Ajdinaj
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Placido Lanza
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Antonino Lupica
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Grazia Crescimanno
- Institute for Biomedical Research and Innovation, National Research Council of Italy, Palermo, Italy
| | - Roberto Monastero
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy.
| | - Antonio Di Muzio
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
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Zawadka-Kunikowska M, Rzepiński Ł, Cieślicka M, Klawe JJ, Tafil-Klawe M. Alterations in short-term blood pressure variability related to disease severity and autonomic symptoms in myasthenia gravis patients. Neurol Sci 2023; 44:4065-4075. [PMID: 37378800 PMCID: PMC10570234 DOI: 10.1007/s10072-023-06927-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/21/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVES We aimed to evaluate beat-to-beat blood pressure variability (BPV) during head-up tilt test (HUTT) in patients with mild and moderate myasthenia gravis (MG) compared to healthy controls (HCs), and its association with the severity of autonomic symptoms. METHODS A total of 50 MG patients and 30 HCs were evaluated. Patients were stratified into 2 groups regarding Myasthenia Gravis Foundation of America (MGFA) classification: mild (I,II MGFA), moderate form (III MGFA). Autonomic symptoms were assessed by COMPASS-31 questionnaire. Cardiovascular parameters, indices of very short-term systolic (SBPV), and diastolic blood pressure (BP) variability (DBPV) were assessed at rest, and during HUTT. RESULTS Moderate MG patients were characterized by an overall shift of sympathovagal balance toward sympathetic predominance, either at rest and during HUTT, as well as lower values of high frequency (HFnu) of DBPV during HUTT, compared to HCs and mild MG. Similarly, moderate MG showed higher resting low frequency (LFnu) of DBPV (p=0.035), higher COMPASS-31 score (p=0.031), and orthostatic intolerance sub-score (p=0.019) than mild MG patients. Compared to HCs, mild MG patients showed lower Δmean BP (p=0.029), Δdiastolic BP (p=0.016). Autonomic symptoms were associated with lower BP values, at rest and during HUTT, and lower LF BPV parameters during HUTT. CONCLUSION MG patients present significant alterations in BPV, both at rest and in response to orthostatic stress, which are related to autonomic symptoms and disease severity. This study confirms the importance of monitoring BPV when evaluating cardiovascular autonomic function and its evolution over the course of MG disease.
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Affiliation(s)
- Monika Zawadka-Kunikowska
- Department of Human Physiology, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092, Bydgoszcz, Poland.
| | - Łukasz Rzepiński
- Sanitas-Neurology Outpatient Clinic, Dworcowa 110, 85-010, Bydgoszcz, Poland
- Department of Neurology, 10th Military Research Hospital and Polyclinic, 85-681, Bydgoszcz, Poland
| | - Mirosława Cieślicka
- Department of Human Physiology, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092, Bydgoszcz, Poland
| | - Jacek J Klawe
- Department of Hygiene, Epidemiology, Ergonomy and Postgraduate Education, Nicolaus Copernicus University in Torun, Ludwik Rydygier Collegium Medicum in Bydgoszcz, M. Sklodowskiej-Curie 9, 85-094, Bydgoszcz, Poland
| | - Małgorzata Tafil-Klawe
- Department of Human Physiology, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Karłowicza 24, 85-092, Bydgoszcz, Poland
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Kasahara H, Shimizu K, Makioka K, Sano T, Ohtaki Y, Ikeda Y. Multimodal immunotherapy ameliorates myasthenia gravis preceded by thymoma-associated multiorgan autoimmunity. Immunol Res 2022; 70:414-418. [PMID: 35288824 DOI: 10.1007/s12026-022-09273-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/24/2022] [Indexed: 11/29/2022]
Abstract
Thymoma-associated multiorgan autoimmunity (TAMA) is a rare autoimmune disorder associated with thymoma that causes a pathology similar to graft-versus-host disease (GVHD) targeting the skin, digestive organs, and liver. Herein, we report the case of a 38-year-old male with myasthenia gravis (MG) preceded by TAMA. The patient developed intractable diarrhea 2 years before admission. Subsequently, dysphagia, dysarthria, and left blepharoptosis were observed. The patient was admitted to the hospital because of fever and dyspnea, was positive for anti-AChR antibody, and chest-computed tomography revealed thymoma, which led to the diagnosis of thymoma-related MG. Biopsied specimens from the sigmoid colon revealed apoptotic colonopathy with lymphocyte-rich lamina propria. Immunohistochemical staining revealed that the infiltrating cells were predominantly labeled with anti-CD3-antibody. The patient did not show skin lesions or liver dysfunction. Therefore, TAMA limited to the gastrointestinal tract was diagnosed. Although TAMA typically has a poor prognosis, immediate multimodal immunotherapy for MG was successful, resulting in a good outcome for TAMA of this case. TAMA is caused by the inability of the thymoma to suppress self-reactive T lymphocytes, which subsequently leads to a disease that is clinically indistinguishable from GVHD. Based on the characteristics of this case, limited gastrointestinal tract involvement in TAMA without lesions in other organs may lead to a favorable prognosis. TAMA cases lacking skin lesions may present with nonspecific gastrointestinal or liver disease. If a patient with thymoma-associated MG has gastrointestinal symptoms such as diarrhea, TAMA should be considered, and the diagnosis should be made early by pathological evaluation of gastrointestinal tissues.
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Affiliation(s)
- Hiroo Kasahara
- Department of Neurology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Kazuki Shimizu
- Department of Neurology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Kouki Makioka
- Department of Neurology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Takaaki Sano
- Department of Diagnostic Pathology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yoichi Ohtaki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yoshio Ikeda
- Department of Neurology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan.
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Shi Y, Wang C. When the Good Syndrome Goes Bad: A Systematic Literature Review. Front Immunol 2021; 12:679556. [PMID: 34113351 PMCID: PMC8185358 DOI: 10.3389/fimmu.2021.679556] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/10/2021] [Indexed: 12/22/2022] Open
Abstract
Background Good syndrome is a rare adult-onset immunodeficiency characterized by thymoma and hypogammaglobulinemia. Its clinical manifestations are highly heterogeneous, ranging from various infections to autoimmunity. Objective This study was to summarize patient characteristics, identify prognostic factors and define clinical subgroups of Good syndrome. Methods A systematic literature review was conducted to include patients with Good syndrome identified in PubMed, Embase and Cochrane databases between January 2010 and November 2020. Logistic and Cox regressions were used to identify prognostic factors impacting outcomes. Clinical subgroups were defined by multiple correspondence analysis and unsupervised hierarchical clustering. A decision tree was constructed to characterize the subgroup placement of cases. Results Of 162 patients included in the current study, the median age at diagnosis was 58 years and 51% were male. Type AB was the most common histological subtype of thymoma, and infections as well as concurrent autoimmune disorders were identified in 92.6% and 51.2% patients, respectively. Laboratory workup showed typical findings of combined immunodeficiency. Thymoma status (odds ratio [OR] 4.157, confidence interval [CI] 1.219-14.177, p = 0.023), infections related to cellular immunity defects (OR 3.324, 95% CI 1.100-10.046, p = 0.033), infections of sinopulmonary tract (OR 14.351, 95% CI 2.525-81.576, p = 0.003), central nerve system (OR 6.403, 95% CI 1.205-34.027, p = 0.029) as well as bloodstream (OR 6.917, 95% CI 1.519-31.505, p = 0.012) were independent prognostic factors. The 10-year overall survival was 53.7%. Cluster analysis revealed three clinical subgroups with distinct characteristics and prognosis (cluster 1, infections related to cellular immunity defects; cluster 2, infections related to other immunity defects; cluster 3, infections related to humoral and phagocytic immunity defects). A decision tree using infection types (related to humoral and cellular immunity defects) could place patients into corresponding clusters with an overall correct prediction of 72.2%. Conclusions Infection type and site were the main prognostic factors impacting survival of patients with Good syndrome. We identified three subgroups within Good syndrome associated with distinct clinical features, which may facilitate the study of underlying pathogenesis as well as development of targeted therapy.
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Affiliation(s)
- Yiyun Shi
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Chen Wang
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
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Chou C, Huang M, Lan W, Kong S, Kuo C, Chou I. Prevalence and risk of thyroid diseases in myasthenia gravis. Acta Neurol Scand 2020; 142:239-247. [PMID: 32329050 DOI: 10.1111/ane.13254] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To estimate the prevalence of thyroid diseases and the cumulative risk of thyroid diseases during a follow-up period after myasthenia gravis (MG) diagnosis compared with non-MG controls. MATERIALS AND METHODS We used the Taiwan National Health Insurance Database linked to Registry of Catastrophic Illness database to identify patients with MG. The controls were composed of those who did not have MG and were matched with the MG patients by sex, age, and the index date. We recorded thyroid disease histories before and after the index date. RESULTS Our study included 5813 MG patients and 29 065 controls. The prevalence of thyroid diseases in the MG patients at diagnosis was 18.4%, which was nearly 3.9-fold greater than that in the control group. (Odds ratio [OR] 3.895, 95% Confidence interval [CI] 3.574-4.246) After excluding pre-existing thyroid diseases, the incidence of comorbid thyroid diseases was 8.7% in the MG patients and 4% in the control group. The MG patients had a 2.36-fold increased risk of developing thyroid diseases compared to the control group. (crude hazard ratio [HR] 2.360, 95% CI 2.095-2.659) The cumulative probabilities of developing thyroid diseases at 1, 5, and 10 years after the index date were 21.6%, 24.9%, and 28.7%, respectively, in the MG patients, while the cumulative probabilities were 6.5%, 8.8%, and 11.8%, respectively, in control group (log-rank test <0.0001). CONCLUSIONS The current population-based study showed a higher prevalence of pre-existing thyroid diseases and a higher cumulative probability of thyroid diseases during follow-up after MG diagnosis than in the general population.
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Affiliation(s)
- Cheng‐Che Chou
- Division of Paediatric Neurology Taipei Medical University Shuang Ho Hospital New Taipei City Taiwan
| | - Man‐Hsu Huang
- Division of Pathology Taipei Medical University Shuang Ho Hospital New Taipei City Taiwan
| | - Wen‐Ching Lan
- Division of Big Data Analytics and Statistics Chang Gung Memorial Hospital, Linko Branch Taoyuan Taiwan
| | - Shu‐Sing Kong
- Division of Paediatric Neurology Taipei Medical University Shuang Ho Hospital New Taipei City Taiwan
| | - Chang‐Fu Kuo
- Division of Rheumatology Chang Gung Memorial Hospital, Linko Branch Taoyuan Taiwan
| | - I‐Jun Chou
- Division of Paediatric Neurology Chang Gung Memorial Hospital and Chang Gung Children’s Hospital, Linko Branch Taoyuan Taiwan
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