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Shi M, Lu Z, Qin A, Cheng J, Chen S, Xing Y. A controlled clinical study on efficacy and safety of periocular triamcinolone acetonide injection for treating ocular myasthenia gravis. BMC Ophthalmol 2024; 24:33. [PMID: 38254041 PMCID: PMC10804469 DOI: 10.1186/s12886-024-03313-z] [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: 05/09/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of peribulbar triamcinolone acetonide injection for treating ocular myasthenia gravis (OMG), with a comparison of traditional oral drug therapy. METHODS A total of 22 patients with OMG who received periocular triamcinolone acetonide injection (initially 20 mg weekly, then once per month later if symptoms were improved) from July 2019 to July 2022 were evaluated by a comparison of symptom degree before and after treatment. Adverse reactions were also monitored during the period of treatment. The period of follow-up was more than 6 months. Additionally, a comparison of the treatment efficacy between this periocular injection and traditional oral administration was performed in OMG patients. RESULTS After 4 weeks of treatment, the degree of ptosis in OMG patients decreased to -3.00 ± 0.69, compared to the value (-0.86 ± 1.32) before treatment. The degree of ophthalmoplegia also decreased from 3.12 ± 0.72 to 0.86 ± 0.88 (P < 0.001) after treatment. The achievement rates of minimal manifestations status (MMS)for ptosis and ophthalmoplegia after 4 week-treatment were 86.3% and 75%, respectively, while they were 50% and 30% in patients with traditional oral administration. There was statistically significant difference only in MMS (rather than symptom relief rate and generalization conversion rate) between two groups. No serious complications (except for intraorbital hematoma) were found in OMG patients during the treatment period. CONCLUSION Repeated peribulbar injection of triamcinolone acetonide can effectively alleviate the initial symptoms of OMG patients. However, the evaluation of its long-term efficacy is still needed. CLINICAL TRIAL REGISTRY This study has been clinically registered by Chinese Clinical Trial Registry (ChiCTR), first trial registration date:05/07/2019, registration number: ChiCTR1900024285.
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Affiliation(s)
- Minghua Shi
- Department of Opthalmology, Aier Eye Hospital of Wuhan University, No. 481, Zhongshan Road, Wuchang District, Wuhan, 430060, China
| | - Zhuneng Lu
- Department of Neurology, RenMin Hospital of Wuhan University, Wuhan, China
| | - Aijiao Qin
- Department of Opthalmology, Aier Eye Hospital of Wuhan University, No. 481, Zhongshan Road, Wuchang District, Wuhan, 430060, China
| | - Jing Cheng
- Department of Opthalmology, Aier Eye Hospital of Wuhan University, No. 481, Zhongshan Road, Wuchang District, Wuhan, 430060, China
| | - Simin Chen
- Department of Opthalmology, Aier Eye Hospital of Wuhan University, No. 481, Zhongshan Road, Wuchang District, Wuhan, 430060, China
| | - Yiqiao Xing
- Department of Opthalmology, Aier Eye Hospital of Wuhan University, No. 481, Zhongshan Road, Wuchang District, Wuhan, 430060, China.
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Çelebisoy N, Orujov A, Balayeva F, Özdemir HN, Ak AK, Gökçay F. Prognostic predictors of remission in ocular myasthenia gravis. Acta Neurol Belg 2023; 123:1927-1932. [PMID: 36474006 DOI: 10.1007/s13760-022-02151-4] [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: 06/18/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ocular myasthenia gravis (OMG) constitutes 15% of all myasthenia gravis patients. METHODS One hundred eight patients with OMG followed-up for over 36 months were retrospectively evaluated regarding factors associated with remission. Demographic features, neuro-ophthalmologic findings at onset, acetylcholine receptor (AChR Ab) and muscle-specifc tyrosine kinase antibodies (MuSK Ab), thymic status, single fiber electromyography (SFEMG) results were the variables considered. RESULTS Median age of disease onset was 57 years (range 18-82 years). Clinical features at onset was isolated ptosis in 55 (50.9%) and isolated diplopia in 33 (30.6%) patients. Combined ptosis and diplopia were present in 20 (18.5%) patients. Among 75 patients with ptosis, it was unilateral in 65 (86.7%) and bilateral in 10 (13.3%). AChR Abs were found in 66 (61.1%) and MuSK Abs in 2 (1.9%) patients. SFEMG abnormality was detected in 74 (68.5%) patients. Thymoma was present in 16 (14.8%) and thymic hyperplasia in 6 (5.6%) patients. Forty-one patients (37.9%) had been treated with pyridostigmine alone. Sixty-seven (62%) patients were given immunosupressive drugs. In 53 (49.1%) prednisone was used and in 14 (12.9%) patients it was combined with azathioprine. Thymectomy was performed in all 16 patients with thymoma. Complete stable remission (CSR) was achieved in 49 (45.4%) patients. Fifty-nine (54.6%) patients had reached minimal manifestation (MM) status; 32 (29.6%) having a status of MM-1 and 27 (25%) a status of MM-3. CONCLUSIONS The presence of AchR Abs (p = 0.034) and an abnormal SFEMG (p = 0.006) at onset as increased risk factors for the presence of ongoing signs necessitating medical treatment.
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Affiliation(s)
- Neşe Çelebisoy
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
| | - Asim Orujov
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
| | - Fidan Balayeva
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
| | | | - Ayşın Kısabay Ak
- Department of Neurology, Celal Bayar University Medical School, 45000, Manisa, Turkey.
| | - Figen Gökçay
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
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Risk for generalization in ocular onset myasthenia gravis: experience from a neuro-ophthalmology clinic. Acta Neurol Belg 2022; 122:337-344. [PMID: 33544334 DOI: 10.1007/s13760-020-01582-1] [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: 10/14/2020] [Accepted: 12/17/2020] [Indexed: 01/13/2023]
Abstract
Conversion to generalized myasthenia gravis (GMG) within the first 2 years has been reported in 18-85% of patients with ocular myasthenia gravis (OMG). The aim of the study was to investigate the risk factors for generalization in patients with OMG admitted to a neuro-ophthalmology clinic and to determine if there were differences between patients with GMG with predominant bulbar (GMG-B) or extremity muscle (GMG-E) involvement according to the 6th and 24th-month Myasthenia Gravis Foundation of America classification ranks. Patients with OMG who were followed-up for at least 24 months were retrospectively analyzed. Demographic, clinical, laboratory features and treatment strategies that can be associated with generalization and time to generalization were evaluated. Of the 139 patients with OMG, 54 (39%) showed generalization with a mean time of 10.3 (range 2-24) months. GMG-B and GMG-E were diagnosed in 31 (22.3%) and 23 patients (16.5%), respectively. Seropositivity for acetylcholine receptor and muscle-specific tyrosine kinase antibodies, abnormal single-fiber electromyography (SFEMG), and the presence of thymic abnormalities (thymoma and hyperplasia) were factors associated with generalization on multivariate analysis without a significant difference between the GMG-B and GMG-E groups. In addition, an abnormal repetitive nerve stimulation test was related to a shortened time to generalization. Bilateral ptosis at onset was found as a risk factor for generalization. In a neuro-ophthalmology clinic, bilateral ptosis as an initial feature of OMG must be approached cautiously because it may be the first sign of impending GMG.
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Johnson S, Katyal N, Narula N, Govindarajan R. Adverse Side Effects Associated with Corticosteroid Therapy: A Study in 39 Patients with Generalized Myasthenia Gravis. Med Sci Monit 2021; 27:e933296. [PMID: 34707081 PMCID: PMC8562011 DOI: 10.12659/msm.933296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background The tolerability of high-dose oral corticosteroids in patients with generalized myasthenia gravis (gMG) has not been systematically assessed. We evaluated adverse side effects (ASEs) of corticosteroid treatment in patients with gMG. Material/Methods Retrospective analysis was conducted of ASEs reported as being related to corticosteroid treatment in 39 patients with gMG who were treated with oral corticosteroids for ≥1 year. Results Median (interquartile range [IQR]) age was 60 (21) years, 53.8% of patients were women, and 66.7% were aged ≤65 years. Median (IQR) prednisone treatment duration was 14 (2) months; median (IQR) daily dose was 40 (15) mg. The median number of ASEs reported as corticosteroid-related was 2/patient (IQR, 1). Pre-diabetes and weight gain were most common (each 43.6% of patients). Bruising, insomnia, and osteoporosis were more prevalent in patients aged >65 years, while irritability, osteopenia, and pre-diabetes were more common in patients aged ≤65 years, although differences were not statistically significant. Irritability and weight gain were more prevalent in women (P=0.010 for irritability); osteoporosis and pre-diabetes more common in men (P=0.015 for osteoporosis). ASEs were generally more common in the high-dose prednisone group (>30 mg/day), but were only statistically significant for irritability (P=0.001). Conclusions Corticosteroid-related ASEs were common in patients with gMG. Some of these ASEs can have serious medical consequences, and certain ASEs appeared to be associated with specific patient characteristics. Demographics and comorbidities of patients with gMG must be carefully considered before corticosteroid initiation. Potential ASEs, such as unanticipated osteoporosis in men, require extra vigilance.
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Affiliation(s)
- Stephen Johnson
- Department of Neurology, Brigham and Women's Hospital and Massachusetts General Hospital, Boston, MA, USA
| | - Nakul Katyal
- Department of Neurology, University of Missouri Health Care, Columbia, MO, USA
| | - Naureen Narula
- Department of Pulmonary and Critical Care, Northwell Health - Staten Island University Hospital, New York City, NY, USA
| | - Raghav Govindarajan
- Department of Neurology, University of Missouri Health Care, Columbia, MO, USA
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Li F, Li Z, Chen Y, Bauer G, Uluk D, Elsner A, Swierzy M, Ismail M, Meisel A, Rückert JC. Thymectomy in ocular myasthenia gravis before generalization results in a higher remission rate. Eur J Cardiothorac Surg 2021; 57:478-487. [PMID: 31628812 DOI: 10.1093/ejcts/ezz275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 08/31/2019] [Accepted: 09/11/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES This study aimed to compare the outcomes of patients with ocular myasthenia gravis (OMG) who underwent thymectomy before generalization with the outcomes of those who underwent thymectomy after generalization. METHODS We retrospectively reviewed patients who underwent robotic thymectomy for myasthenia gravis between January 2003 and February 2018. Patients who presented with purely ocular symptoms at myasthenia gravis onset were eligible for inclusion. Exclusion criteria were patients who were lost to follow-up and patients who underwent re-thymectomy. Patients with OMG who developed generalization before thymectomy were categorized into gOMG group and those who did not were categorized into OMG group. The primary outcome was complete stable remission according to the Myasthenia Gravis Foundation of America Post-Intervention Status (MGFA-PIS). RESULTS One hundred and sixty-five (66 males and 99 females) out of 596 patients with myasthenia gravis were eligible for inclusion. Of these, there were 73 and 92 patients undergoing thymectomy before and after the generalization of OMG, respectively. After propensity score matching, a data set of 130 patients (65 per group) was formed and evaluating results showed no statistical differences between the 2 groups. The estimated cumulative probabilities of complete stable remission at 5 years were 49.5% [95% confidence interval (CI) 0.345-0.611] in the OMG group and 33.4% (95% CI 0.176-0.462) in the gOMG group (P = 0.0053). Similar results were also found in patients with non-thymomatous subgroup [55 patients per group, OMG vs gOMG, 53.5% (95% CI 0.370-0.656) vs 28.9% (95% CI 0.131-0.419), P = 0.0041]. CONCLUSIONS Thymectomy in OMG before generalization might result in a higher rate of complete stable remission than thymectomy after generalization.
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Affiliation(s)
- Feng Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Zhongmin Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Yanli Chen
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Gero Bauer
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Deniz Uluk
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Aron Elsner
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Marc Swierzy
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Mahmoud Ismail
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Integrated Center for Myasthenia Gravis, NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Charité - University Medicine Berlin, Berlin, Germany
| | - Jens-C Rückert
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
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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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Abstract
PURPOSE OF REVIEW Ocular myasthenia gravis (OMG) is a complex condition with heterogenous phenotypes and ill-defined diagnostic criteria. Understanding concomitant risk factors and autoimmune serology can help inform prognosis for generalization and guide treatment. RECENT FINDINGS Although antibodies to acetylcholine receptors or muscle-specific kinase likely increase risk of generalization, they are less frequent in OMG. Patients without either antibody tend to have a milder disease process and often have variable antibodies to other end-plate proteins such as LRP4, agrin, or cortactin. The treatment of OMG begins with pyridostigmine and is supplemented by oral prednisone if treatment-resistant or high risk for generalization. Variable oral prednisone regimens have been used with success and further immunosuppression may be best achieved with mycophenolate mofetil and azathioprine. Checkpoint inhibitor-induced myasthenia gravis is increasingly recognized and likely has high rates of mortality associated with myocarditis. SUMMARY Our understanding of OMG and its variable phenotypes continues to evolve. Autoantibody testing increasingly provides valuable diagnostic and prognostic information. Despite these improvements, a lack of quality treatment trials creates significant challenges for evidence-based management guidelines.
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Outcomes of Juvenile Myasthenia Gravis: A Comparison of Robotic Thymectomy With Medication Treatment. Ann Thorac Surg 2021; 113:295-301. [PMID: 33482164 DOI: 10.1016/j.athoracsur.2020.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 09/20/2020] [Accepted: 12/30/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The study aimed to compare the clinical outcomes of patients with juvenile myasthenia gravis (MG) who underwent robotic thymectomy with that of those who only received medication therapy. METHODS We retrospectively reviewed patients who visited our institution for the diagnosis or treatment of MG with an age at onset younger than 18 years. Patients who underwent thymectomy comprised the surgical group and those who received only medication therapy comprised the nonsurgical group. The clinical outcomes were assessed according to the Myasthenia Gravis Foundation of America Post-Intervention Status. RESULTS Forty-seven patients (35 female, 12 male) were included as the surgical group and 20 patients (15 female, 5 male) comprised the nonsurgical group. Significant differences were observed between the surgical and nonsurgical groups in antibody against acetylcholinesterase receptor (91.5% vs 65%; P = .012), disease duration (median 16 [interquartile range, 7-25] months vs 96 [interquartile range, 42-480] months; P < .001), and corticosteroids requirement (53.2% vs 15%; P = .004) at baseline. Kaplan-Meier analysis showed a higher cumulative probability of complete stable remission in the surgical group (P = .002) compared with the nonsurgical group. Moreover, thymectomy (hazard ratio, 3.842; 95% confidence interval, 1.116-13.230; P = .033) and age at onset (hazard ratio, 0.89; 95% confidence interval, 0.80-0.99; P = .037) were still associated with the achievement of complete stable remission in the multivariable analysis. Furthermore, a significant steroid-sparing effect was observed in the surgical group but not in the nonsurgical group. CONCLUSIONS Robotic thymectomy seems to be more effective than medication therapy on juvenile MG in terms of inducing remission and reducing the use of corticosteroids.
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Liu X, Zhou W, Hu J, Hu M, Gao W, Zhang S, Zeng W. Prognostic predictors of remission in ocular myasthenia after thymectomy. J Thorac Dis 2020; 12:422-430. [PMID: 32274108 PMCID: PMC7139038 DOI: 10.21037/jtd.2020.01.17] [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] [Indexed: 12/22/2022]
Abstract
Background Identifying prognostic predictors can assist in making clinical decisions. This study aimed to identify the potential predictors of remission in patients with ocular myasthenia gravis (OMG) after thymectomy. Methods OMG patients who had thymectomy between 2011 and 2017 were reviewed retrospectively. Clinical outcomes were assessed according to the Myasthenia Gravis Foundation of America Post-Intervention Status (MGFA-PIS). Kaplan-Meier analysis was used to estimate the cumulative probability of complete stable remission (CSR). Univariate and multivariable analyses with Cox proportional hazards regression were used to identify predictors of CSR. Results Fifty-one patients (23 male, 28 female) with a median age at OMG onset of 40 (range, 5-79) years were eligible for inclusion. Patients with thymomatous OMG (n=9) had a statistically older median age at disease onset [61 (range, 32-78) vs. 33.5 (range, 5-79) years, P=0.001], shorter duration from disease onset to thymectomy [3 (range, 2-24) vs. 10 (range, 1-132) months, P=0.004], and a higher rate of postoperative complication (44.4% vs. 9.5%, P=0.025), compared with non-thymomatous OMG (n=42). The estimated cumulative probability of CSR in the whole cohort was 41.8% (95% CI, 28.6-58.2%) 5 years after surgery. Age at onset of 40 years or younger (P=0.00016), female sex (P=0.069), and thymic hyperplasia (P=0.0061) were potential predictors under univariate analysis. However, only age at onset of 40 years or younger (HR: 4.117, 95% CI, 1.177-14.399, P=0.027) remained significant after multivariable analysis. Conclusions CSR could be achieved in about 40% of OMG patients 5 years after thymectomy and is likely to be predicted by age at onset of 40 years or younger.
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Affiliation(s)
- Xiang Liu
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Wangyan Zhou
- Department of Medical Humanities and Education Department, the First Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Jun Hu
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Mingsong Hu
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Wenkui Gao
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Shan Zhang
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Wei Zeng
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
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Maintenance immunosuppression in myasthenia gravis, an update. J Neurol Sci 2019; 410:116648. [PMID: 31901719 DOI: 10.1016/j.jns.2019.116648] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/25/2019] [Accepted: 12/24/2019] [Indexed: 01/08/2023]
Abstract
Therapies for myasthenia gravis (MG) include symptomatic and immunosuppressive/immunomodulatory treatment. Options for immunosuppression include corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, tacrolimus, methotrexate, rituximab, cyclophosphamide, eculizumab, intravenous immunoglobulin, subcutaneous immunoglobulin, plasmapheresis, and thymectomy. The practical aspects of long-term immunosuppressive therapy in MG are critically reviewed in this article. Application of one or more of these specific therapies is guided based on known efficacy, adverse effect profile, particular disease subtype and severity, and patient co-morbidities.
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Li F, Li Z, Takahashi R, Ioannis A, Ismail M, Meisel A, Rueckert JC. Robotic-Extended Rethymectomy for Refractory Myasthenia Gravis: A Case Series. Semin Thorac Cardiovasc Surg 2019; 32:593-602. [PMID: 31682904 DOI: 10.1053/j.semtcvs.2019.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 10/25/2019] [Indexed: 11/11/2022]
Abstract
To assess the safety and efficacy of robotic-extended rethymectomy in selected refractory myasthenia gravis (MG) patients with suspected residual thymic tissue. Robotic-extended rethymectomy was performed in 6 MG patients with seropositive acetylcholine receptors (AChR) antibody who had undergone a previous thymectomy (1 cervicotomy, 2 video-assisted thoracoscopic surgeries, and 3 sternotomies). The median observation time before robotic rethymectomy was 108 (24-171) months. The main outcomes were perioperative morbidity, mortality, conversion to open surgery, and clinical outcomes according to the Myasthenia Gravis Foundation of America Post-Intervention Status (MGFA-PIS). Before rethymectomy, all patients required immunosuppressants and 5 patients (83.3%) required intravenous immune globulin and/or plasma exchange to control the symptoms. The median specimen weight was 24.5 (14-144) g after rethymectomy, and residual thymic tissue was found in 5 patients (83.3%). No conversion to open surgery or perioperative morbidity and mortality was observed. With a median follow-up time of 46.5 (13-155) months, 3 patients (50%) achieved "improved" and 3 (50%) were "unchanged" according to the MGFA-PIS. Compared with preoperative use, the median daily dose of corticosteroids statistically decreased (25 [7.5-60] vs 0 [0-5] mg, P = 0.002) without significant change in azathioprine use (100 [0-200] vs 50 [0-150] mg, P = 0.360). AChR antibody positive MG patients with a treatment refractory long-term course after thymectomy might have remaining thymic tissue with the 2 commonly associated thymus pathologies, thymoma, and follicular hyperplasia. Robotic-extended rethymectomy might be considered as a safe and beneficial treatment option in these patients.
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Affiliation(s)
- Feng Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Zhongmin Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Reona Takahashi
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | | | - Mahmoud Ismail
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology Berlin, Charité University Hospital Berlin, Berlin, Germany
| | - Jens-C Rueckert
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany.
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