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Liu Y, Chen S, Wang Y, Zhang Z, Wang Z, Tao Z, Wang J, Zhang P. The Diagnostic and Prognostic Value of the Immune Checkpoint BGN in Thymoma. Biochem Genet 2024; 62:1872-1894. [PMID: 37776467 DOI: 10.1007/s10528-023-10523-5] [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: 06/12/2023] [Accepted: 09/07/2023] [Indexed: 10/02/2023]
Abstract
Thymoma is frequently correlated with various autoimmune diseases. However, unequivocal therapeutic targets for thymoma remain undefined, and the role of immune checkpoints in the development of thymoma-related autoimmune illnesses is unclear. We examined 39 thymoma samples and 44 normal control samples from the GEO database. Following batch correction, we identified 224 Differentially Expressed Genes (DEGs) using the Limma package. We employed Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses to enrich for functional pathways of DEGs. We utilized a Protein-Protein Interaction (PPI) network to identify hub genes and determine their correlation with immune cell infiltration using CIBERSORT. Real-time quantitative polymerase chain reaction (RT-qPCR), western blot, and immunohistochemical staining were implemented to verify identified hub genes in vivo. Simultaneously, we evaluated the prognostic relevance of the hub gene using clinical data. We determined COL1A1, COL1A2, and BGN to be the central hub genes in thymoma. Validation via RT-qPCR, Western blot, and immunohistochemical staining established significant statistical divergence between thymoma tissue and the normal thymus for only BGN. Expression levels of BGN showed strong negative correlation with the infiltration level of B cells and CD4+ T cells, yet a significant positive correlation with the level of neutrophil infiltration. We found high immune infiltration levels of macrophages, NK cells, and Th1 cells in the thymoma microenvironment in patients with a high expression of BGN. Co-localization of BGN and macrophages within thymoma tissue was discerned via tissue staining. Clinical data dictated that thymoma patients exhibiting elevated BGN expression underwent longer hospital stays, longer lengths in intensive care units, greater hospitalization costs, and extended ventilator usage; our study, augmented by clinical information, recognized BGN as possessive of diagnostic and prognostic significance in thymoma through in silico and molecular verification experiments. Our findings offered an important objective for thymoma-treated autoimmune disease comprehension, supplemented by the strong association with immune infiltration.
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Affiliation(s)
- Yuxin Liu
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Si Chen
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Yan Wang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Zeyang Zhang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Ziyi Wang
- School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Ziyou Tao
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, China
| | - Jianyao Wang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Peng Zhang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China.
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2
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Igoe A, Merjanah S, Harley ITW, Clark DH, Sun C, Kaufman KM, Harley JB, Kaelber DC, Scofield RH. Association between systemic lupus erythematosus and myasthenia gravis: A population-based National Study. Clin Immunol 2024; 260:109810. [PMID: 37949200 DOI: 10.1016/j.clim.2023.109810] [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: 09/15/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are autoimmune diseases. Previous case reports and case series suggest an association may exist between these diseases, as well as an increased risk of SLE after thymectomy for MG. We undertook this study to determine whether SLE and MG were associated in large cohorts. METHODS We searched the IBM Watson Health Explorys platform and the Department of Veterans Affairs Million Veteran Program (MVP) database for diagnoses of SLE and MG. In addition, we examined subjects enrolled in the Lupus Family Registry and Repository (LFRR) as well as controls for a diagnosis of MG. RESULTS Among 59,780,210 individuals captured in Explorys, there were 25,750 with MG and 65,370 with SLE. 370 subjects had both. Those with MG were >10 times more likely to have SLE than those without MG. Those with both diseases were more likely to be women, African American, and at a younger age than MG subjects without SLE. In addition, the MG patients who underwent thymectomy had an increased risk of SLE compared to MG patients who had not undergone thymectomy (OR 3.11, 95% CI: 2.12 to 4.55). Autoimmune diseases such as pernicious anemia and miscellaneous comorbidities such as chronic kidney disease were significantly more common in MG patients who developed SLE. In the MVP, SLE and MG were also significantly associated. Association of SLE and MG in a large SLE cohort with rigorous SLE classification confirmed the association of SLE with MG at a similar level. CONCLUSION While the number of patients with both MG and SLE is small, SLE and MG are strongly associated together in very large databases and a large SLE cohort.
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Affiliation(s)
- Ann Igoe
- OhioHealth Hospital, Rheumatology Department, Mansfield, OH 44903, USA
| | - Sali Merjanah
- Boston University Medical Center, Section of Rheumatology, Department of Medicine, Boston, MA 02118, USA
| | - Isaac T W Harley
- Division of Rheumatology, Departments of Medicine and Immunology/Microbiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; Medicine Service, Rheumatology Section, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO 80045, USA
| | - Dennis H Clark
- Research Service, US Department of Veterans Affairs Medical Center, Cincinnati, OH, USA
| | - Celi Sun
- Research Service, US Department of Veterans Affairs Medical Center, Oklahoma City, OK 73104, USA
| | - Kenneth M Kaufman
- Research Service, US Department of Veterans Affairs Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - John B Harley
- Research Service, US Department of Veterans Affairs Medical Center, Cincinnati, OH, USA; Cincinnati Education and Research for Veterans Foundation, Cincinnati, OH, USA
| | - David C Kaelber
- Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine and The Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH 44109, USA
| | - R Hal Scofield
- Research Service, US Department of Veterans Affairs Medical Center, Oklahoma City, OK 73104, USA; Department of Medicine, University of Oklahoma Health Sciences Center, Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, and Medical/Research Service, and Medicine Service, US Department of Veterans Affairs Medical Center, Oklahoma City, OK 73104, USA.
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3
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Zhu Y, Wang B, Hao Y, Zhu R. Clinical features of myasthenia gravis with neurological and systemic autoimmune diseases. Front Immunol 2023; 14:1223322. [PMID: 37781409 PMCID: PMC10538566 DOI: 10.3389/fimmu.2023.1223322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/23/2023] [Indexed: 10/03/2023] Open
Abstract
Multiple reports on the co-existence of autoimmune diseases and myasthenia gravis (MG) have raised considerable concern. Therefore, we reviewed autoimmune diseases in MG to explore their clinical presentations and determine whether the presence of autoimmune diseases affects the disease severity and treatment strategies for MG. We reviewed all the major immune-mediated coexisting autoimmune conditions associated with MG. PubMed, Embase and Web of Science were searched for relevant studies from their inception to January 2023. There is a higher frequency of concomitant autoimmune diseases in patients with MG than in the general population with a marked risk in women. Most autoimmune comorbidities are linked to AChR-MG; however, there are few reports of MuSK-MG. Thyroid disorders, systemic lupus erythematosus, and vitiligo are the most common system autoimmune diseases associated with MG. In addition, MG can coexist with neurological autoimmune diseases, such as neuromyelitis optica (NMO), inflammatory myopathy (IM), multiple sclerosis (MS), and autoimmune encephalitis (AE), with NMO being the most common. Autoimmune diseases appear to develop more often in early-onset MG (EOMG). MS coexists more commonly with EOMG, while IM coexists with LOMG. In addition, MG complicated by autoimmune diseases tends to have mild clinical manifestations, and the coexistence of autoimmune diseases does not influence the clinical course of MG. The clinical course of neurological autoimmune diseases is typically severe. Autoimmune diseases occur most often after MG or as a combined abnormality; therefore, timely thymectomy followed by immunotherapy could be effective. In addition, thymoma-associated AChR MG is associated with an increased risk of AE and IM, whereas NMO and MS are associated with thymic hyperplasia. The co-occurrence of MG and autoimmune diseases could be attributed to similar immunological mechanisms with different targets and common genetic factor predisposition. This review provides evidence of the association between MG and several comorbid autoimmune diseases.
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Affiliation(s)
| | | | | | - Ruixia Zhu
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
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4
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Dar S, Koirala S, Khan A, Bellary MD, Patel AV, Mathew B, Singh R, Baigam N, Razzaq W, Abdin ZU, Khawaja UA. A Comprehensive Literature Review on Managing Systemic Lupus Erythematosus: Addressing Cardiovascular Disease Risk in Females and Its Autoimmune Disease Associations. Cureus 2023; 15:e43725. [PMID: 37727166 PMCID: PMC10505685 DOI: 10.7759/cureus.43725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023] Open
Abstract
This review aimed to evaluate the mechanism of premature cardiovascular disease (CVD) in systemic lupus erythematosus (SLE) patients, particularly in the female population, and emphasize the need for early management interventions; explore the association between SLE and two autoimmune diseases, myasthenia gravis (MG) and antiphospholipid antibody syndrome (APS), and their management strategies; and evaluate the effectiveness of pharmacological and non-pharmacological interventions in managing SLE, focusing on premenopausal females, females of childbearing age, and pregnant patients. We conducted a comprehensive literature review to achieve these objectives using various databases, including PubMed, Google Scholar, and Cochrane. The collected data were analyzed and synthesized to provide an evidence-based overview of SLE, its management strategies as an independent disease, and some disease associations. The treatment should be focused on remission, preventing organ damage, and improving the overall quality of life (QOL). Extensive emphasis should also be focused on diagnosing SLE and concurrent underlying secondary diseases timely and managing them appropriately.
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Affiliation(s)
- Saleha Dar
- Department of Adult Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sabina Koirala
- Department of Medicine, Gandaki Medical College, Pokhara, NPL
| | - Arooba Khan
- Department of Internal Medicine, Khyber Medical College, Peshawar, PAK
| | | | - Arya V Patel
- Department of Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Bejoi Mathew
- Department of Internal Medicine, Sri Devaraj Urs Medical College, Kolar, IND
| | - Rahul Singh
- Department of Medicine, Armed Forces Medical College, Pune, IND
| | - Nahida Baigam
- Department of Medicine, Association of Physicians of Pakistani Descent of North America (APPNA), Westmont, USA
| | - Waleed Razzaq
- Department of Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Department of Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Uzzam Ahmed Khawaja
- Department of Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Department of Clinical and Translational Research, Dr. Ferrer BioPharma, South Miami, USA
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Patki AY, Durga P, Gangishetty A, Ketireddy T, Noorain N. Myasthenia Gravis: An Unanticipated Cause of Failure to Wean in a Postpartum Patient with Pre-existing Systemic Lupus Erythematosus. Indian J Crit Care Med 2022; 26:731-732. [PMID: 35836638 PMCID: PMC9237154 DOI: 10.5005/jp-journals-10071-24228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Sudden onset and de novo Myasthenia gravis (MG) in the presence of systemic lupus erythematosus (SLE) is a rare postpartum phenomenon and can easily misguide the treating physician. A known case of SLE, 4 days after an elective cesarean section, presented to the intensive care unit for weaning-off mechanical ventilation after being put on ventilatory support in the emergency room, following acute-onset partial seizures. She was subsequently diagnosed to have new-onset MG, treated for the condition and later successfully extubated.
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Affiliation(s)
- Abhiruchi Y Patki
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
- Abhiruchi Y Patki, Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India, Phone: +91 9177909339, e-mail:
| | - Padmaja Durga
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Alekhya Gangishetty
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Tejasri Ketireddy
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Naqiya Noorain
- Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Singhal S, Hellyer J, Ouseph MM, Wakelee HA, Padda SK. Autoimmune Disease in Patients with Advanced Thymic Epithelial Tumors. JTO Clin Res Rep 2022; 3:100323. [PMID: 35601925 PMCID: PMC9121321 DOI: 10.1016/j.jtocrr.2022.100323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/31/2022] [Accepted: 04/02/2022] [Indexed: 11/01/2022] Open
Abstract
Introduction Methods Results Conclusions
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Kobza A, Keenan M, Ivory C. Mixed connective tissue disease after thymectomy in refractory myasthenia gravis. Rheumatol Int 2021; 42:2077-2084. [PMID: 34432146 DOI: 10.1007/s00296-021-04976-3] [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: 06/30/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
Connective tissue diseases, including systemic lupus erythematosus (SLE) and systemic sclerosis are classic models of autoimmunity; diseases with large-scale loss of tolerance and subsequent development of pathogenic autoreactive lymphocytes and tissue targeting autoantibodies. Here we report a case of mixed connective tissue disease, with features of systemic lupus erythematosus and systemic sclerosis developing in a patient 10 years post thymectomy for myasthenia gravis. The patient developed acute cutaneous lupus, Raynaud's with digital ulcers, arthritis and lymphopenia. Her myasthenia continued to be resistant to treatment and her rheumatic disease progressed despite aggressive therapy. We performed a database search of MEDLINE, EMBASE, Scopus, and Web of Science for articles of similar cases post thymectomy from inception to August 2021, using the terms "systemic lupus erythematosus" (or systemic sclerosis, or connective tissue disease) and "myasthenia gravis" and "thymectomy". We identified 41 cases, 28 of SLE post thymectomy, 8 related to systemic sclerosis, 5 with mixed connective tissue disease and highlighted their different presentation and serology. We explore the role of the thymus, tolerance and myasthenia gravis in the development of connective tissue disease. This highlights the complexity of concurrent autoimmune diseases and their autoantibodies.
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Affiliation(s)
- Alexandra Kobza
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Marissa Keenan
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Rheumatology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Catherine Ivory
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Division of Rheumatology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada. .,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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8
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Lupus eritematoso sistémico postimectomía en pacientes con miastenia gravis: a propósito de tres casos clínicos. Neurologia 2021; 36:82-83. [DOI: 10.1016/j.nrl.2019.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/19/2019] [Accepted: 12/12/2019] [Indexed: 11/18/2022] Open
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9
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Alba Isasi M, López Sánchez J, Vázquez Lorenzo J, Fuentes Rumi M. Systemic lupus erythematosus in patients with myasthenia gravis undergoing thymectomy: report of 3 clinical cases. NEUROLOGÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.nrleng.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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10
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Raut S, Reddy I, Sahi FM, Masood A, Malik BH. Association Between Systemic Lupus Erythematosus and Myasthenia Gravis: Coincidence or Sequelae? Cureus 2020; 12:e8422. [PMID: 32642338 PMCID: PMC7336596 DOI: 10.7759/cureus.8422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease and myasthenia gravis (MG) is an organ-specific autoimmune disease, both may exhibit positive anti-nuclear antibodies and a female preponderance. They may have similar features and can coexist in a patient or precede one another. This review article is based on electronic searches using PubMed as the primary database. Most of the articles used for this review were published in the last ten years with the exception of seven articles which were from 1995-2009. No guidelines have been followed. A total of 55 research articles were found related to the topic of this review article, and further scanning was done to eliminate some articles that did not meet the criteria. The coexistence of autoimmune diseases has been reported in many cases. The prevalence of a second autoimmune disease is higher among patients with a primary diagnosis of autoimmune disease than the general population. The prevalence of SLE in MG patients or vice-versa is greater than the general population. The association has been hypothesized to many mechanisms: thymectomy resulting in loss of central tolerance and generation of autoantibodies, regulatory T cell dysfunction, the dysregulated function of Fas receptor (CD95), anti-malarial drugs directly affecting the neuromuscular junction, the role of chemokine CXCL13 and GM-CSF in the pathogenesis. The association is rare, and the presence of one should be closely followed for further progression into other diseases. More research work needs to be done for a clear conclusion.
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Affiliation(s)
- Sumit Raut
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ishani Reddy
- Psychiatry and Behavioral Sciences, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Faryal Mustansir Sahi
- Dermatology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ayesha Masood
- General Surgery, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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Mollaeian A, Haas C. A tale of autoimmunity: thymoma, thymectomy, and systemic lupus erythematosus. Clin Rheumatol 2020; 39:2227-2234. [PMID: 32277368 PMCID: PMC7295737 DOI: 10.1007/s10067-020-05061-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/18/2020] [Accepted: 03/20/2020] [Indexed: 12/15/2022]
Abstract
The thymus plays an integral role in immune system regulation, modulating the development, diversity, and selection of T lymphocytes, a critical feature for the prevention of T cell-mediated autoimmunity. Thymoma is a rare tumor of the thymus. Autoimmune diseases and paraneoplastic syndromes such as myasthenia gravis, pure red blood cell aplasia, and systemic lupus erythematosus, although relatively uncommon, have been described in association with thymomas. Rare cases of post-thymectomy autoimmune related diseases, including systemic lupus erythematosus and pure red cell aplasia, have been reported in the literature. Here, we present the case of a 65-year-old male who developed systemic lupus erythematosus 2 years after thymectomy in the setting of thymoma-associated pure red cell aplasia.
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Affiliation(s)
- Arash Mollaeian
- MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA.
| | - Christopher Haas
- MedStar Health Internal Medicine Residency Program, Baltimore, MD, USA.,Georgetown University School of Medicine, Washington, DC, USA
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12
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Nagarajan M, Maasila AT, Dhanapriya J, Dineshkumar T, Sakthirajan R, Rajasekar D, Balasubramaniyan T, Gopalakrishnan N. Systemic Lupus Erythematosus and Myasthenia Gravis: A Rare Association. Indian J Nephrol 2019; 29:62-64. [PMID: 30814797 PMCID: PMC6375012 DOI: 10.4103/ijn.ijn_12_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are two autoimmune diseases that have a higher incidence in young females, relapsing-remitting course, and positive antinuclear antibodies. SLE and MG are two different clinical syndromes, which can coexist or precede each other; however, their occurrence in the same patient is rare. We report a 38-year-old female with biopsy-proven lupus nephritis on steroids and cyclophosphamide, later developed MG. Nerve conduction studies showed the decremental response of 15%-25% over facial muscles with no decremental response over limb muscles. Although antianticholinesterase receptor (AchR) antibodies were negative, she was treated with oral pyridostigmine 60 mg twice daily and clinical improvement of ocular symptoms was seen within 48 h. At present, she is on oral prednisolone and mycophenolate mofetil with follow-up creatinine of 1.4 mg/dl and no neurological symptoms.
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Affiliation(s)
- M Nagarajan
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - A T Maasila
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - J Dhanapriya
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - T Dineshkumar
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - R Sakthirajan
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - D Rajasekar
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - T Balasubramaniyan
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - N Gopalakrishnan
- Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
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13
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Tanovska N, Novotni G, Sazdova-Burneska S, Kuzmanovski I, Boshkovski B, Kondov G, Jovanovski-Srceva M, Kokareva A, Isjanovska R. Myasthenia Gravis and Associated Diseases. Open Access Maced J Med Sci 2018; 6:472-478. [PMID: 29610603 PMCID: PMC5874368 DOI: 10.3889/oamjms.2018.110] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/03/2018] [Accepted: 02/04/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND: Myasthenia gravis (MG) is an autoimmune disease caused by the action of specific antibodies to the postsynaptic membrane of the neuromuscular junction, leading to impaired neuromuscular transmission. Patients with MG have an increased incidence of other autoimmune diseases. AIM: to determine the presence of other associated diseases in patients with MG. METHOD: A group of 127 patients with MG followed in 10 years period, in which the presence of other associated diseases has been analysed. RESULTS: The sex ratio is in favour of the female sex, the average age of the initial manifestation of the disease is less than 50 years, 65.4% of the patients with MG have another disease. 15.0% patients have associated another autoimmune disease. Thyroid disease is the most common associated with MG, rarely rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and other autoimmune diseases. Other diseases include hypertension, heart disease, diabetes, respiratory diseases, dyslipidemia. 10.2% of the patients are diagnosed with extrathymic tumours of various origins. CONCLUSION: Associated diseases are common in patients with MG, drawing attention to the possible common basis for their coexistence, as well as their impact on the intensity and treatment of the disease.
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Affiliation(s)
- Nikolina Tanovska
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Gabriela Novotni
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Slobodanka Sazdova-Burneska
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Igor Kuzmanovski
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Bojan Boshkovski
- University Clinic for Neurology, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Goran Kondov
- University Clinic for Thoracic and Vascular Surgery, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Marija Jovanovski-Srceva
- University Clinic for Anesthesia and Reanimation, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Anita Kokareva
- University Clinic for Anesthesia and Reanimation, Clinical Centre "Mother Theresa", Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Rozalinda Isjanovska
- Institute for Epidemiology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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Abstract
The association between thymoma and autoimmunity is well known. Besides myasthenia gravis, which is found in 15 to 20% of patients with thymoma, other autoimmune diseases have been reported: erythroblastopenia, systemic lupus erythematosus, inflammatory myopathies, thyroid disorders, Isaac's syndrome or Good's syndrome. More anecdotally, Morvan's syndrome, limbic encephalitis, other autoimmune cytopenias, autoimmune hepatitis, and bullous skin diseases (pemphigus, lichen) have been reported. Autoimmune diseases occur most often before thymectomy, but they can be discovered at the time of surgery or later. Two situations require the systematic investigation of a thymoma: the occurrence of myasthenia gravis or autoimmune erythroblastopenia. Nevertheless, the late onset of systemic lupus erythematosus or the association of several autoimmune manifestations should lead to look for a thymoma. Neither the characteristics of the patients nor the pathological data can predict the occurrence of an autoimmune disease after thymectomy. Thus, thymectomy usefulness in the course of the autoimmune disease, except myasthenia gravis, has not been demonstrated. This seems to indicate the preponderant role of self-reactive T lymphocytes distributed in the peripheral immune system prior to surgery. Given the high infectious morbidity in patients with thymoma, immunoglobulin replacement therapy should be considered in patients with hypogammaglobulinemia who receive immunosuppressive therapy, even in the absence of prior infection.
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Iijima T, Hoshino J, Takaichi K, Kohno T, Fujii T, Ohashi K, Ubara Y. Lupus Nephritis with Thymoma Managed by Thoracoscopic Surgery and Prednisolone. Intern Med 2017; 56:3311-3316. [PMID: 29249764 PMCID: PMC5790719 DOI: 10.2169/internalmedicine.8966-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
A 48-year-old woman was admitted to our hospital to undergo evaluation for fatigue, severe weight loss, and nephrotic range proteinuria. Light microscopy of a renal biopsy specimen revealed class III (A) lupus nephritis, while immunofluorescence and electron microscopy only showed sparse immune deposits with findings that were not typical of lupus nephritis. Computed tomography revealed a mass in the anterior mediastinum, which was resected. The examination of the surgical specimen revealed type A noninvasive thymoma. In combination with thymomectomy, postoperative steroid therapy achieved the prompt remission of lupus nephritis. In this patient, thymoma-related autoimmunity may have contributed to the exacerbation of lupus nephritis.
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Affiliation(s)
| | | | - Kenmei Takaichi
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Tadashi Kohno
- Department of Chest Surgery, Toranomon Hospital, Japan
| | | | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Japan
- Department of Pathology, Yokohama City University, Graduate School of Medicine, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
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Rao S, George MK, Shobha V, Sarma G. Systemic lupus erythematosus and myasthenia gravis: More common than we think? INDIAN JOURNAL OF RHEUMATOLOGY 2016. [DOI: 10.1016/j.injr.2015.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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17
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Miskovic R, Plavsic A, Peric-Popadic A, Raskovic S, Bogic M. Systemic Lupus Erythematosus and Secondary Antiphospholipid Syndrome after Thymectomy for Myasthenia Gravis - A Case Report. Open Access Maced J Med Sci 2015; 3:439-42. [PMID: 27275267 PMCID: PMC4877836 DOI: 10.3889/oamjms.2015.096] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 08/15/2015] [Accepted: 08/23/2015] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION: Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are autoimmune diseases that show some similarities: a higher incidence in young women, relapsing-remitting course and positive anti-nuclear antibodies (ANA). However, they are two different clinical syndromes, which can coexist or precede each other. Thymectomy is a therapeutic option for patients with severe MG or thymoma. There are many cases of SLE after thymectomy described in the literature, so the question arises whether thymectomy predisposes patients to SLE and what are imunopathogenetic mechanisms behind this process. CASE REPORT: We report a case of a patient who was diagnosed with SLE and secondary antiphospholipid syndrome (APS) 28 years after thymectomy for MG. Clinical picture of SLE was characterized by cutaneous and articular manifestations, polyserositis, lupus nephritis and immunological parameters showed positive ANA, anti-ds-DNA, excessive consumption of complement components, positive cryoglobulins. Clinical and laboratory immunological parameters for the diagnosis of secondary APS where also present. The patient was initially treated with glucocorticoids followed by mycophenolate mofetil. During one year follow-up patient was in a stable remission of SLE. CONCLUSION: Thymectomy for MG may predispose SLE development in some patients. Further studies are needed to better understand the connection between these two autoimmune diseases.
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Affiliation(s)
- Rada Miskovic
- Clinical Center of Serbia, Clinic for Allergology and Immunology, Belgrade, Serbia
| | - Aleksandra Plavsic
- Clinical Center of Serbia, Clinic for Allergology and Immunology, Belgrade, Serbia
| | | | - Sanvila Raskovic
- Clinical Center of Serbia, Clinic for Allergology and Immunology, Belgrade, Serbia
| | - Mirjana Bogic
- Clinical Center of Serbia, Clinic for Allergology and Immunology, Belgrade, Serbia
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Bekircan-Kurt CE, Tuncer Kurne A, Erdem-Ozdamar S, Kalyoncu U, Karabudak R, Tan E. The course of myasthenia gravis with systemic lupus erythematosus. Eur Neurol 2014; 72:326-9. [PMID: 25323839 DOI: 10.1159/000365568] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 06/30/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is one of the autoimmune diseases, which is rarely reported with Myasthenia Gravis (MG). In the literature, the clinical features of MG in these patients were not mentioned in detail. Here, we want to present our five patients with MG and SLE. METHODS Between 2000 and 2010, 132 MG patients were evaluated and have been followed up in our institution. Five patients had MG with SLE and eleven patients had antinuclear antibody (ANA) positivity without SLE symptoms. The clinical, laboratory findings and treatment responses were reviewed. RESULTS All patients had generalized MG and four of five patients experienced at least one myasthenic crisis. The response to corticosteroid was poor; consequently, they needed immunosuppressive treatments, IVIg or plasmapheresis. Although in the literature thymectomy was accused of the precipitation of SLE, in our series SLE symptoms preceded thymectomy. CONCLUSION We would like to point out that MG and SLE being two autoimmune diseases may coexist. This coexistence might cause a more severe myasthenic course compared to MG alone; therefore, these patients need a close and frequent follow-up.
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Affiliation(s)
- Can Ebru Bekircan-Kurt
- Department of Neurology, Hacettepe University School of Medicine, Sıhhiye, Ankara, Turkey
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Iwadate H, Kobayashi H, Shio K, Noguchi E, Watanabe K, Sasajima T, Sekine H, Watanabe H, Ohira H, Obara K, Sato Y. A case of systemic lupus erythematosus complicated by pure red cell aplasia and idiopathic portal hypertension after thymectomy. Mod Rheumatol 2014. [DOI: 10.3109/s10165-006-0465-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Abstract
AbstractSystemic lupus erythematosus (SLE) and myasthenia gravis (MG) are autoimmune diseases, their association in the same patient being rarely described. Here, we report a case of SLE in a 19-year-old girl who within 2 years of the diagnosis of SLE developed MG, and underwent thymectomy for a benign thymoma immediately thereafter.
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Agrawal M, Rahmani R, Nakkala K, Fiel MI, Schiano T. Hepatoportal sclerosis (obliterative portal venopathy) and nodular regenerative hyperplasia in a patient with myasthenia gravis: A case report and review of the published work. Hepatol Res 2013; 43:999-1003. [PMID: 23675894 DOI: 10.1111/hepr.12045] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 11/29/2012] [Accepted: 12/13/2012] [Indexed: 12/14/2022]
Abstract
Nodular regenerative hyperplasia (NRH) and hepatoportal sclerosis, also known as obliterative portal venopathy (OPV), are two causes of non-cirrhotic portal hypertension (NCPH). NCPH is an increasingly recognized entity that can be seen in association with collagen vascular diseases and with the use of medications such as azathioprine and didanosine, but oftentimes the etiology remains unidentified. We herein report a case of NCPH occurring due to OPV and NRH in a 64-year-old woman with myasthenia gravis (MG), status post-thymectomy. Portal hypertension was diagnosed incidentally on computed tomography in the absence of predisposing factors. Extensive work-up to determine the etiology of any underlying liver disease was unrevealing. NRH and OPV were identified on liver biopsy. Subsequently, the patient had variceal bleeding that necessitated transjugular intrahepatic portosystemic shunt placement. A few similar cases of NCPH occurring in the setting of MG have been previously reported, suggesting that the immunological mechanisms involved in the pathogenesis of myasthenia may also have contributed to the development of NCPH.
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Affiliation(s)
- Manasi Agrawal
- Department of Internal Medicine, Division of Gastroenterology, Maimonides Medical Center, Brooklyn
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The association of systemic lupus erythematosus and myasthenia gravis: a series of 17 cases, with a special focus on hydroxychloroquine use and a review of the literature. J Neurol 2011; 259:1290-7. [PMID: 22160434 DOI: 10.1007/s00415-011-6335-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 11/16/2011] [Accepted: 11/17/2011] [Indexed: 01/19/2023]
Abstract
The coexistence of systemic lupus erythematosus (SLE) and myasthenia gravis (MG) is rarely reported, and most of the published studies are case reports. Hydroxychloroquine, an antimalarial agent, is an essential treatment in patients with SLE but special caution is recommended when used in MG patients. We retrospectively analyzed the clinical features, laboratory findings, and outcome of 17 patients with both diseases with a special focus regarding hydroxychloroquine use and with a review of the literature. All patients were women. The mean age at MG onset and SLE diagnosis was 34.5 [14-64] and 37.8 [18-72] years, respectively. The presenting symptoms of MG were limb weakness (94%), ocular (88%) and bulbar involvement (53%). Autoantibodies against the acetylcholine receptor were positive in 94% of cases. The main manifestations of SLE included arthritis (88%), cytopenias (53%) and skin rash (41%). Treatment of SLE required hydroxychloroquine (94%), steroids (47%) and immunosuppressive drugs (18%). Among eight patients (47%) who developed MG after initiation of hydroxychloroquine, the question of induction of MG by hydroxychloroquine was raised in one patient. On the other hand, an exacerbation of myasthenic symptoms was only seen in one of the eight patients who received hydroxychloroquine after the diagnosis of MG. Including our cases, we reviewed a total of 70 patients with SLE and MG. Compared with a large series of 1,000 unselected SLE patients, those with associated MG were older, had lower incidence of cutaneous, renal, and neurological manifestations, and higher frequency of anticardiolipin antibodies and lupus anticoagulant. In conclusion, the clinical pattern of patients with SLE and MG seems to be characterized by a less severe course of SLE and higher frequency of antiphospholipid antibodies. Hydroxychloroquine treatment appears to be safe in this setting.
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Castrejón I, Shum K, Tseng CE, Askanase A. Association between myasthaenia gravis and systemic lupus erythematosus: three case reports and review of the literature. Scand J Rheumatol 2011; 40:486-90. [DOI: 10.3109/03009742.2011.575077] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
The thymus is a central lymphatic organ that is responsible for many immunological functions, including the production of mature, functional T cells and the induction of self-tolerance. Benign or malignant tumors may originate from the thymus gland, with thymoma being the most common and accounting for 50% of anterior mediastinal tumors. Malignancies linked to thymoma include the loss of self-tolerance and the presence of autoimmunity. In this review, we compiled the current scientific evidence detailing the various interactions between thymoma and autoimmune diseases, including myasthenia gravis, systemic lupus erythematosus, inappropriate antidiuretic hormone secretion, pure red cell aplasia, pernicious anemia, pemphigus and autoimmune thyroid diseases. In recent years, several mechanisms have been proposed to explain these interactions. Most are based on the assumption that the 'sick' thymus, like the 'normal' thymus, can generate mature T cells; however, the T cells generated by the sick thymus are impaired and thus may exert cellular autoreactivity. Here, we present several theories that may shed light on the loss of self-tolerance associated with this epithelial tumor of the thymus.
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25
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Souirti Z, Chtaou N, Lakranbi M, Smahi M, Messouak O, Belahsen M. Lupus érythémateux aigu systémique après thymectomie. Rev Med Interne 2010; 31:e10-2. [DOI: 10.1016/j.revmed.2009.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Revised: 06/04/2009] [Accepted: 08/17/2009] [Indexed: 11/30/2022]
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26
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Systemic lupus erythematosus after thymectomy for myasthenia gravis: a case report and review of the literature. Clin Exp Nephrol 2010; 14:272-6. [DOI: 10.1007/s10157-009-0256-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Accepted: 11/20/2009] [Indexed: 11/26/2022]
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27
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Hrycek A. A sequence of pathologic events in a patient after thymectomy for myasthenia gravis. Rheumatol Int 2009; 32:245-8. [DOI: 10.1007/s00296-009-1301-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Accepted: 11/29/2009] [Indexed: 11/27/2022]
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28
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Figueiredo-Braga M, Mota-Garcia F, O'Connor JE, Garcia JR, Mota-Cardoso R, Cardoso CS, de Sousa M. Cytokines and anxiety in systemic lupus erythematosus (SLE) patients not receiving antidepressant medication: a little-explored frontier and some of its brief history. Ann N Y Acad Sci 2009; 1173:286-91. [PMID: 19758164 DOI: 10.1111/j.1749-6632.2009.04647.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Autoimmunity travelled from the theoretical roots planted by Burnet with the clonal selection theory and the early finding of a mouse providing a test for the role of the thymus as a source of forbidden clones. This chapter briefly reviews early work with the NZB mouse and presents results of an analysis of associations between cytokines and physical and psychometric parameters in systemic lupus erythematosus (SLE) patients not medicated with antidepressants. Some cytokines, particularly IFN-gamma, relate significantly to physical symptoms and anxiety. We conclude with the speculation that anxiety is linked to innate immunity and more severe neuropsychiatric disease in SLE to adaptive immunity.
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29
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30
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Iwadate H, Kobayashi H, Shio K, Noguchi E, Watanabe K, Sasajima T, Sekine H, Watanabe H, Ohira H, Obara K, Sato Y. A case of systemic lupus erythematosus complicated by pure red cell aplasia and idiopathic portal hypertension after thymectomy. Mod Rheumatol 2006; 16:109-12. [PMID: 16633932 DOI: 10.1007/s10165-006-0465-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2005] [Accepted: 02/21/2006] [Indexed: 10/24/2022]
Abstract
We describe a 49-year-old woman who presented in 2002 with pure red cell aplasia (PRCA), systemic lupus erythematosus (SLE), and idiopathic portal hypertension (IPH) that developed following a thymectomy. She underwent a thymectomy at 40 years of age to treat myasthenia gravis. PRCA developed 3 years after the thymectomy and she was successfully treated with cyclosporin. Systemic lupus erythematosus and IPH were diagnosed 6 years later. We conclude that immunological dysfunction resulting from the thymectomy contributed significantly to the subsequent development of PRCA, SLE, and IPH in this patient. This is the first report to describe this extremely rare occurrence.
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Affiliation(s)
- Haruyo Iwadate
- Department of Internal Medicine II, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
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Bhinder S, Majithia V, Harisdangkul V. Myasthenia gravis and systemic lupus erythematosus: truly associated or coincidental-two case reports and review of the literature. Clin Rheumatol 2005; 25:555-6. [PMID: 16328087 DOI: 10.1007/s10067-005-0099-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Accepted: 06/21/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Sumeet Bhinder
- University of Mississippi Medical Center, 2500 N State St., L-525, Jackson, MS 39216, USA.
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32
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Sarin A, Saxena V. An Unusual Case of Autoimmune Disease. APOLLO MEDICINE 2005. [DOI: 10.1016/s0976-0016(11)60265-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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