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Ouyang S, Yin W, Zeng Q, Li B, Zhang J, Duan W, Li Y, Liang Y, Wang J, Tan H, Yang H. Lymphoplasma Exchange Improves Myasthenia Gravis Exacerbations: A Retrospective Study in a Chinese Center. Front Immunol 2022; 13:757841. [PMID: 35514988 PMCID: PMC9063637 DOI: 10.3389/fimmu.2022.757841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 03/16/2022] [Indexed: 12/04/2022] Open
Abstract
Background Lymphoplasma exchange (LPE), a technique combining plasma exchange with leukapheresis, is emerging as promising treatment for autoimmune diseases. Data on the efficacy and safety of LPE in myasthenia gravis (MG) therapy are scarce. In this study, we aimed to comprehensively review the clinical efficacy, safety, and immunological characteristics of LPE therapy in MG patients. Study Design and Methods A Chinese cohort of 276 generalized MG patients in state of exacerbation, including impeding crisis, myasthenia crisis, and preparation for thoracic exsection between January 2014 and December 2020, were evaluated in this study. Results A total of 276 patients with a median age of 45.5 ± 16.7 years underwent a total of 635 LPE sessions. Clinical scales of Quantitative Myasthenia Gravis (QMG) scores, Myasthenia Gravis Specific Manual Muscle Testing (MMT) scores, activities of daily living (ADL) scores, and quality of life (QOL) scores were improved during 4 weeks’ follow-up. Adverse effects occurred in 20 out of 276 patients, with 14 patients having one adverse event each. Independent predictive factors for good response to LPE therapy were symptom onset before LPE therapy ≤3 days and age on LPE therapy <50 years of age. LPE decreased the serum levels of antibodies, immunoglobulins, and complements 4 weeks after the first replacement, with decreased levels of interleukin (IL)-17A and interferon (IFN)-γ and increased level of IL-10. Conclusion LPE is an effective treatment for MG patients in state of exacerbation and preparation for thymectomy. Early use of LPE on early-onset MG may have good therapeutic effects. The potential mechanism for LPE is the polarization of cytokines from IL-17A, IFN-γ, into IL-10.
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Affiliation(s)
- Song Ouyang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- Medical Center of Neurology, The First Hospital of Changsha City, South China University, Changsha, China
| | - Weifan Yin
- The Second Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Huan Yang, ; Weifan Yin,
| | - Qiuming Zeng
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Bijuan Li
- Department of Blood Transfusion, Xiangya Hospital, Central South University, Changsha, China
| | - Jian Zhang
- Department of Pathology, University of Iowa, Iowa City, IA, United States
| | - Weiwei Duan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yong Liang
- Medical Center of Neurology, The First Hospital of Changsha City, South China University, Changsha, China
| | - Jiaqi Wang
- Medical Center of Neurology, The First Hospital of Changsha City, South China University, Changsha, China
| | - Hong Tan
- Medical Center of Neurology, The First Hospital of Changsha City, South China University, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Huan Yang, ; Weifan Yin,
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Exploring the Gut Microbiome in Myasthenia Gravis. Nutrients 2022; 14:nu14081647. [PMID: 35458209 PMCID: PMC9027283 DOI: 10.3390/nu14081647] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 12/13/2022] Open
Abstract
The human gut microbiota is vital for maintaining human health in terms of immune system homeostasis. Perturbations in the composition and function of microbiota have been associated with several autoimmune disorders, including myasthenia gravis (MG), a neuromuscular condition associated with varying weakness and rapid fatigue of the skeletal muscles triggered by the host’s antibodies against the acetylcholine receptor (AChR) in the postsynaptic muscle membrane at the neuromuscular junction (NMJ). It is hypothesized that perturbation of the gut microbiota is associated with the pathogenesis of MG. The gut microbiota community profiles are usually generated using 16S rRNA gene sequencing. Compared to healthy individuals, MG participants had an altered gut microbiota’s relative abundance of bacterial taxa, particularly with a drop in Clostridium. The microbial diversity related to MG severity and the overall fecal short-chain fatty acids (SCFAs) were lower in MG subjects. Changes were also found in terms of serum biomarkers and fecal metabolites. A link was found between the bacterial Operational Taxonomic Unit (OTU), some metabolite biomarkers, and MG’s clinical symptoms. There were also variations in microbial and metabolic markers, which, in combination, could be used as an MG diagnostic tool, and interventions via fecal microbiota transplant (FMT) could affect MG development. Probiotics may influence MG by restoring the gut microbiome imbalance, aiding the prevention of MG, and lowering the risk of gut inflammation by normalizing serum biomarkers. Hence, this review will discuss how alterations of gut microbiome composition and function relate to MG and the benefits of gut modulation.
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Li J, Qi G, Liu Y. Effect of Buzhong Yiqi decoction on anti-acetylcholine receptor antibody and clinical status in juvenile ocular myasthenia gravis. Medicine (Baltimore) 2021; 100:e27688. [PMID: 34871253 PMCID: PMC8568406 DOI: 10.1097/md.0000000000027688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/18/2021] [Indexed: 01/21/2023] Open
Abstract
Ocular myasthenia gravis (MG) is the mainly widespread type of MG among juveniles. Buzhong Yiqi decoction (BZ) is a well-known traditional Chinese medicine prescription for treating MG. It has rarely been discussed whether the concentration of anti-acetylcholine receptor (AChR) antibodies is related to the clinical status of juvenile ocular myasthenia gravis (JOMG) treated with BZ.The patients with JOMG who had more than once AChR-antibody (ab) test and treated with BZ were retrospectively identified from June 2013 to January 2020 in the first hospital in Shijiazhuang. The presence or absence of ocular symptoms was used to grade the effectiveness of treatment. Generalized estimating equations logistic regression analysis was used to evaluate the effect of AChR ab concentration on the clinical status of MG.A total of 549 AChR-ab tests were performed in 135 patients, and the corresponding clinical status was recorded. One hundred two patients received treatment with BZ only and 33 combined with immunosuppressive drugs. In the group receiving only BZ treatment, the anti-acetylcholine receptor ab concentration was positively correlated with the clinical score after treatment.The results suggest that BZ could affect the AChR-ab. Repeated AChR-ab assays can provide information about the clinical status. For JOMG patients who only receive Buzhong Yiqi Decoction treatment, this can support treatment decisions.
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Affiliation(s)
- Jiaduo Li
- Center of Treatment of Myasthenia Gravis, People‘s Hospital of Shijiazhuang Affiliated to Hebei Medical University, China
| | - Guoyan Qi
- Center of Treatment of Myasthenia Gravis, People‘s Hospital of Shijiazhuang Affiliated to Hebei Medical University, China
| | - Yaling Liu
- Gastroenterology Department, People‘s Hospital of Shijiazhuang Affiliated to Hebei Medical University, China
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Payedimarri AB, Ratti M, Rescinito R, Vasile A, Seys D, Dumas H, Vanhaecht K, Panella M. Development of a Model Care Pathway for Myasthenia Gravis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11591. [PMID: 34770107 PMCID: PMC8582978 DOI: 10.3390/ijerph182111591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/29/2021] [Accepted: 10/31/2021] [Indexed: 12/21/2022]
Abstract
Myasthenia Gravis (MG) is a chronic, life-lasting condition that requires high coordination among different professionals and disciplines. The diagnosis of MG is often delayed and sometimes misdiagnosed. The goal of the care pathway (CP) is to add value to healthcare reducing unnecessary variations. The quality of the care received by patients affected with MG could benefit from the use of CP. We conducted a study aimed to define an inclusive, comprehensive, and multidisciplinary CP for the diagnosis, treatment, and care of MG. The development of the model CP, key interventions, and process indicators is based on the literature review and 85 international MG experts were involved in their evaluation, expressing a judgment of relevance through the Delphi study. 60 activities are included in the model CP and evaluated by the MG experts were valid and feasible. The 60 activities were then translated into 14 key interventions and 24 process indicators. We believe that the developed model CP will help for MG patients to have a timely diagnosis and high-quality, accessible, and cost-effective treatments and care. We also believe that the development of model CPs for other rare diseases is feasible and could aid in the integration of evidence-based knowledge into clinical practice.
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Affiliation(s)
- Anil babu Payedimarri
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Matteo Ratti
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Riccardo Rescinito
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Alessandra Vasile
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
| | - Deborah Seys
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, 3000 Leuven, Belgium
| | | | - Kris Vanhaecht
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, 3000 Leuven, Belgium
- Department of Quality Management, University Hospitals Leuven, University of Leuven, 3000 Leuven, Belgium
| | - Massimiliano Panella
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, 28100 Novara, Italy; (M.R.); (R.R.); (A.V.); (M.P.)
- European Pathway Association, 3000 Leuven, Belgium; (D.S.); (K.V.)
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Ipe TS, Meyer EK, Sanford KW, Joshi SK, Wong ECC, Raval JS. Use of therapeutic plasma exchange for pediatric neurological diseases. J Clin Apher 2020; 36:161-176. [PMID: 33063869 DOI: 10.1002/jca.21850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/10/2020] [Accepted: 10/02/2020] [Indexed: 12/19/2022]
Abstract
Therapeutic plasma exchange is used to treat neurological diseases in the pediatric population. Since its first use in pediatric patients with hepatic coma in the form of manual whole blood exchange, therapeutic plasma exchange has been increasingly used to treat these disorders of the nervous system. This expansion is a result of improved techniques and apheresis instruments suitable for small children, as well as the recognition of its applicability to many diseases in the pediatric population. This review provides a historical overview of the use of therapeutic apheresis in children and highlights the most common applications for therapeutic plasma exchange to treat neurological disorders in children.
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Affiliation(s)
- Tina S Ipe
- Department of Pathology and Laboratory Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Erin K Meyer
- American Red Cross, Columbus, Ohio, USA.,Department of Pathology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kimberly W Sanford
- Department of Pathology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sarita K Joshi
- Department of Hematology/Oncology and Bone Marrow Transplant, University of Washington, Seattle, Washington, USA
| | - Edward C C Wong
- Department of Pediatrics and Pathology, George Washington School of Medicine and Health Sciences, Washington, District of Columbia, USA.,Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Jay S Raval
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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6
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Delly F, Syed MJ, Lisak RP, Zutshi D. Myasthenic crisis in COVID-19. J Neurol Sci 2020; 414:116888. [PMID: 32413767 PMCID: PMC7200364 DOI: 10.1016/j.jns.2020.116888] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/12/2022]
Abstract
Myasthenic crises is a potentially severe complication of COVID-19. Hydroxychloroquine can aggravate myasthenia crises. IVIg is a potential treatment for both Myasthenic crises and COVID-19. IVIg treatment may cause thrombosis in susceptible patients.
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Affiliation(s)
- Fadi Delly
- Henry Ford Health Systems, Wyandotte, MI 48192, USA
| | - Maryam J Syed
- Department of Neurology, Wayne State University and Detroit Medical Center, Detroit, MI 48201, USA
| | - Robert P Lisak
- Department of Neurology, Wayne State University and Detroit Medical Center, Detroit, MI 48201, USA; Department of Biochemistry, Microbiology and Immunology, Wayne State University, Detroit, MI 48201, USA
| | - Deepti Zutshi
- Department of Neurology, Wayne State University and Detroit Medical Center, Detroit, MI 48201, USA.
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8
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Prabhakar H, Ali Z. Intensive Care Management of the Neuromuscular Patient. TEXTBOOK OF NEUROANESTHESIA AND NEUROCRITICAL CARE 2019. [PMCID: PMC7120052 DOI: 10.1007/978-981-13-3390-3_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neuromuscular emergencies are a distinct group of acute neurological diseases with distinct characteristic presentations. Patients who suffer from this group of diseases are at immediate risk of losing protection of their native airway as well as aspirating orogastric contents. This is secondary to weakness of the muscles of the oropharynx and respiratory muscles. Although some neuromuscular emergencies such as myasthenia gravis or Guillain-Barré syndrome are well understood, others such as critical illness myopathy and neuropathy are less well characterized. In this chapter, we have discussed the pathophysiology, diagnostic evaluation, and management options in patients who are admitted to the intensive care unit. We have also emphasized the importance of a thorough understanding of the use of pharmacological anesthetic agents in this patient population.
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Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Zulfiqar Ali
- Division of Neuroanesthesiology, Department of Anesthesiology, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir India
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de Carvalho TP, Vianna CL, Andrade FF, Alvarenga RA, Sales LDOM, Rodrigues RS, Rosado-de-Castro PH. Asymmetric pattern in generalized myasthenia gravis: A case report. Medicine (Baltimore) 2018; 97:e13460. [PMID: 30544431 PMCID: PMC6310581 DOI: 10.1097/md.0000000000013460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Myasthenia gravis (MG) is an uncommon autoimmune disease mediated by antibodies that attack the postsynaptic acetylcholine receptors (AchRs) at the neuromuscular junction, causing fluctuating muscle weakness, aggravated with use, and relieved with rest. PATIENT CONCERNS A 32-year-old woman with a diagnosis of MG based on clinical findings, eletroneuromyography, and brain magnetic resonance imaging (MRI) was admitted to our hospital with dysphagia, dysphonia, diplopia, and intense weakness, associated with a 2-day viral gastroenteritis. DIAGNOSES Physical examination revealed globally reduced deep tendon reflexes, and tetraparesis, with muscle strength grade 4 in the left limbs and grade 2 in the right limbs. Autoantibody dosing against AchR was elevated and computed tomography scan of the thorax revealed a thymic remnant. INTERVENTIONS Pyridostigmine and human immunoglobulin were infused. OUTCOMES After 7 days of the reintroduction of pyridostigmine and human immunoglobulin infusion, the patient developed complete resolution of symptoms, being discharged from the hospital. Her symptoms are still well controlled 6 months later. The patient was evaluated by a thoracic surgeon and is awaiting elective thymectomy. LESSONS Although our patient presented all the diagnostic criteria of MG, the markedly asymmetric limb weakness presented in previous history and clinical examination of admission was an unusual and unexpected presentation, especially considering the pathophysiology of the disease. MRI of brain without abnormalities was fundamental to rule out another associated etiology. Our review of the literature revealed just 1 case report of MG with similar presentation. This clinical manifestation becomes valuable because it contributes to the list of unexpected presentation that should motivate its suspicion.
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Affiliation(s)
| | | | | | | | | | - Rosana Souza Rodrigues
- Federal University of Rio de Janeiro
- D’Or Institute for Research and Education, Rio de Janeiro, Brazil
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Fang TK, Yan CJ, Du J. CTLA-4 methylation regulates the pathogenesis of myasthenia gravis and the expression of related cytokines. Medicine (Baltimore) 2018; 97:e0620. [PMID: 29718870 PMCID: PMC6393147 DOI: 10.1097/md.0000000000010620] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 04/09/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is a progressive autoimmune disease that occurs as a result of the failure of neuromuscular transmission and is characterized by muscle weakness. There has been evidence on the correlations between the genetic predisposition of cytotoxic T lymphocyte and the antigen-4 (CTLA-4) and MG. Thus, the present study was conducted to study is designed to examine the effects of CTLA-4 methylation on the pathogenesis of MG and the expressions of related cytokines. METHODS The CTLA-4 methylation levels in peripheral blood were quantified in 103 samples collected from MG patients and 86 samples from healthy individiuals. The expression of serum-related cytokines as well as the Treg cell ratio were examined so as to define the contributory role of CTLA-4 methylation in MG and to identify the interaction between CTLA-4 methylation and related factors, the expressions of DNA methyltransferase (DNMT)l, DNMT3A and DNMT3B, CTLA-4, AchR-Ab, Titin-Ab, RyR-Ab, IL-2, IL-10, IFN-γ, and TGF-β, activity of P- acetylcholinesterase (AchE) and E-AchE. RESULTS The results indicated that the incidence of CTLA-4 methylation was significantly higher in the control group when compared with the MG group, and CTLA-4 methylation was also found to be associated with the thymus status of MG patients. It was also observed from the experiment data that the expressions of DNMTl, DNMT3A, and DNMT3B, along with the expressions of AchR-Ab, Titin-Ab, RyR-Ab, IL-2, IL-10, IFN-γ and TGF-β, and the activity of P-AchE and E-AchE were all higher in the MG group than in the control group, with a reduction of CTLA-4 expression. Another key finding from this study revealed that methylation interference can lead to the suppression in the expression of AchR-Ab, the activity of E-AchE, the expression of IL-2, IL-10, IFN-γ, and TGF-β and the Treg cell ratio in lymphocytes. CONCLUSION In conclusion, the results obtained from the present study highly indicated that CTLA-4 methylation might play a role in facilitating the occurrence of MG and increasing the expressions of related cytokines through the upregulation of AchR-Ab and E-Ach.
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San Norberto EM, García-Saiz I, Gutiérrez D, Domingos L, Vaquero C. Ocular Myasthenia Induced by Rivaroxaban in Patient with Deep Vein Thrombosis. Ann Vasc Surg 2018; 49:313.e1-313.e3. [PMID: 29455019 DOI: 10.1016/j.avsg.2017.11.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/15/2017] [Accepted: 11/02/2017] [Indexed: 11/29/2022]
Abstract
The non-vitamin K antagonist oral anticoagulant rivaroxaban is indicated in prevention and treatment of venous thromboembolism (VTE). A 60-year-old male patient complained of bilateral ptosis after administration of rivaroxaban for deep vein thrombosis (DVT). Myasthenia gravis (MG) was confirmed by positive serum antiacetylcholine receptor antibody test. No mediastinal thymoma was found. The ocular myasthenia reversed after discontinuing rivaroxaban treatment. Nevertheless, ptosis recurred and chronic oral pyridostigmine bromide treatment was necessary. The mechanism of MG development by rivaroxaban therapy is not completely understood. The development of rivaroxaban-induced autoimmune disease could be based on cross-reactivity between antibodies against rivaroxaban-derived antigens or by T-cell activation. To our knowledge, this report of ocular myasthenia by rivaroxaban administration is the first in the literature. Despite the benefits of rivaroxaban, it is important to recognize unexpected immune-related adverse events.
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Affiliation(s)
| | - Irene García-Saiz
- Division of Anesthesia and Critic Care, University Hospital Rio Hortega, Valladolid, Spain
| | - Diana Gutiérrez
- Division of Vascular Surgery, Valladolid University Hospital, Valladolid, Spain
| | - Liliana Domingos
- Division of Vascular Surgery, Valladolid University Hospital, Valladolid, Spain
| | - Carlos Vaquero
- Division of Vascular Surgery, Valladolid University Hospital, Valladolid, Spain
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Induction of Anti-agrin Antibodies Causes Myasthenia Gravis in Mice. Neuroscience 2018; 373:113-121. [PMID: 29339325 DOI: 10.1016/j.neuroscience.2018.01.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/27/2017] [Accepted: 01/05/2018] [Indexed: 11/21/2022]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction (NMJ). Most cases of MG are caused by autoantibodies against the acetylcholine receptor (AChR), muscle-specific kinase (MuSK) and low-density lipoprotein receptor-related protein 4 (LRP4). Recent studies have identified anti-agrin antibodies in MG patients lacking these three antibodies (i.e., triple negative MG). Agrin is a basal lamina protein that has two isoforms. Neural agrin (N-agrin) binds to LRP4 to activate MuSK to induce AChR clusters and is thus critical for NMJ formation. We demonstrate that mice immunized with N-agrin showed MG-associated symptoms including muscle weakness, fragmented and distorted NMJs. These effects were not observed in mice injected with muscle agrin (M-agrin), an isoform that is inactive in inducing AChR clusters. Treatment with anti-N-agrin, but not anti-M-agrin, antibodies reduced agrin-induced AChR clusters in muscle cells. Together, these observations suggest that agrin antibodies may be play a role in MG pathogenesis.
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13
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Abstract
Myasthenia gravis (MG) is an autoimmune disease involving the neuromuscular junction. Autoantibodies to the acetylcholine receptor or, less frequently, to muscle-specific kinase, attack against the postsynaptic junctional proteins, resulting in fluctuating and variable weakness of muscles. Extraocular, levator palpebrae superioris, and orbicularis oculi muscles are particularly susceptible. The majority of patients with MG present with purely ocular symptoms including ptosis and diplopia initially. About half of these patients progress to generalized disease within 2 years. The prevalence of MG in Taiwan is 140 per million with male to female ratio of 0.7. The incidence rate is higher in the elderly. Several immune-related diseases such as lymphoid malignancy, diabetes, and thyroid diseases are associated with MG in the national population-based studies in Taiwan. Ice pack test, rest test, Tensilon/neostigmine test, circulating antibody measurement, and electrophysiological studies are useful diagnostic tools with variable sensitivity and specificity. For the patients with ocular MG, acetylcholinesterase inhibitors are usually the first-line treatment. Corticosteroids and immunosuppressant could provide better disease control and may reduce the risk of conversion to generalized form although there is still some controversy. A thymectomy is also beneficial for ocular MG, especially in refractory cases. The correction of ptosis and strabismus surgery could improve the visual outcome but should be performed only in stable disease.
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Affiliation(s)
- Chao-Wen Lin
- National Taiwan University Hospital, Taipei City, Taiwan
| | - Ta-Ching Chen
- National Taiwan University Hospital, Taipei City, Taiwan
| | - Jieh-Ren Jou
- National Taiwan University Hospital, Taipei City, Taiwan.,Changhua Christian Hospital, Changhua, Taiwan
| | - Lin-Chung Woung
- National Taiwan University Hospital, Taipei City, Taiwan.,Taipei City Hospital, Taipei City, Taiwan
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Azzolin VF, Barbisan F, Lenz LS, Teixeira CF, Fortuna M, Duarte T, Duarte MMFM, da Cruz IBM. Effects of Pyridostigmine bromide on SH-SY5Y cells: An in vitro neuroblastoma neurotoxicity model. MUTATION RESEARCH-GENETIC TOXICOLOGY AND ENVIRONMENTAL MUTAGENESIS 2017; 823:1-10. [DOI: 10.1016/j.mrgentox.2017.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 08/16/2017] [Accepted: 08/22/2017] [Indexed: 10/19/2022]
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15
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Pathological Findings in Myasthenia Gravis Patients with Thymic Hyperplasia and Thymoma. Pathol Oncol Res 2017; 24:67-74. [DOI: 10.1007/s12253-017-0213-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 02/16/2017] [Indexed: 12/28/2022]
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16
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Cao Y, Lu X, Wang J, Zhang H, Liu Z, Xu S, Wang T, Ning S, Xiao B, Wang L. Construction of an miRNA-regulated drug-pathway network reveals drug repurposing candidates for myasthenia gravis. Int J Mol Med 2017; 39:268-278. [PMID: 28075449 PMCID: PMC5358695 DOI: 10.3892/ijmm.2017.2853] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 01/04/2017] [Indexed: 12/31/2022] Open
Abstract
Myasthenia gravis (MG) is a rare debilitating autoimmune neuromuscular disorder. Many studies have focused on the mechanism and treatment strategies of MG. However, the exact pathogenesis of MG and effective treatment strategies remain unclear. Recent studies have indicated that microRNAs (miRNAs or miRs) can regulate the pathological pathways of MG, suggesting their potential role in novel treatments. In the present study, we created a comprehensive catalog of experimentally confirmed MG risk genes and miRNAs by manually mining published literature and public databases. Based on these genes and miRNAs, we identified 41 MG risk pathways and 105 approved drugs that can affect these pathways. Some important MG-related pathways, such as hsa04060 (cytokine-cytokine receptor interaction) and hsa05200 (pathway in cancer), were found to be regulated by MG risk miRNAs and drugs. Furthermore, we constructed an miRNA-regulated drug-pathway network and identified miRNAs and drugs that synergistically regulate key MG pathways and biological processes. We developed a drug repurposing strategy to identify 25 drug repurposing candidates for MG; several of these drugs, such as rituximab, adalimumab, sunitinib, and muromonab, have the potential to be novel MG treatment drugs. This study provides novel insight into the pathogenesis of MG and potential drug candidates for MG were identified.
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Affiliation(s)
- Yuze Cao
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang 150081, P.R. China
| | - Xiaoyan Lu
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang 150081, P.R. China
| | - Jianjian Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang 150081, P.R. China
| | - Huixue Zhang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang 150081, P.R. China
| | - Zhaojun Liu
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang 150081, P.R. China
| | - Si Xu
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang 150081, P.R. China
| | - Tianfeng Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang 150081, P.R. China
| | - Shangwei Ning
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, Heilongjiang 150081, P.R. China
| | - Bo Xiao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang 150081, P.R. China
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Nair AG, Patil-Chhablani P, Venkatramani DV, Gandhi RA. Ocular myasthenia gravis: a review. Indian J Ophthalmol 2016; 62:985-91. [PMID: 25449931 PMCID: PMC4278125 DOI: 10.4103/0301-4738.145987] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Myasthenia gravis (MG) is a disease that affects the neuro-muscular junction resulting in classical symptoms of variable muscle weakness and fatigability. It is called the great masquerader owing to its varied clinical presentations. Very often, a patient of MG may present to the ophthalmologist given that a large proportion of patients with systemic myasthenia have ocular involvement either at presentation or during the later course of the disease. The treatment of ocular MG involves both the neurologist and ophthalmologist. Thus, the aim of this review was to highlight the current diagnosis, investigations, and treatment of ocular MG.
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Affiliation(s)
| | - Preeti Patil-Chhablani
- Department of Strabismus and Neuro-Ophthalmology, Jasti V Ramanamma Children's Eye Care Centre, Hyderabad, Telangana, India
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Gupta A, Goyal V, Srivastava AK, Shukla G, Behari M. Remission And relapse of myasthenia gravis on long-term azathioprine: An ambispective study. Muscle Nerve 2016; 54:405-12. [DOI: 10.1002/mus.25052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 01/11/2016] [Accepted: 01/14/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Anirban Gupta
- Department of Neurology, Cardiothoracic and Neurosciences Centre, Room 706; All India Institute of Medical Sciences; New Delhi 110029 India
| | - Vinay Goyal
- Department of Neurology, Cardiothoracic and Neurosciences Centre, Room 706; All India Institute of Medical Sciences; New Delhi 110029 India
| | - Achal Kumar Srivastava
- Department of Neurology, Cardiothoracic and Neurosciences Centre, Room 706; All India Institute of Medical Sciences; New Delhi 110029 India
| | - Garima Shukla
- Department of Neurology, Cardiothoracic and Neurosciences Centre, Room 706; All India Institute of Medical Sciences; New Delhi 110029 India
| | - Madhuri Behari
- Department of Neurology, Cardiothoracic and Neurosciences Centre, Room 706; All India Institute of Medical Sciences; New Delhi 110029 India
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Zou J, Su C, Lun X, Liu W, Yang W, Zhong B, Zhu H, Lei Y, Luo H, Chen Z. Preoperative Anxiety in Patients With Myasthenia Gravis and Risk for Myasthenic Crisis After Extended Transsternal Thymectomy: A CONSORT Study. Medicine (Baltimore) 2016; 95:e2828. [PMID: 26962777 PMCID: PMC4998858 DOI: 10.1097/md.0000000000002828] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A thymectomy can ameliorate the symptoms of myasthenia gravis (MG) and prevent the progression of ocular MG (OMG) to generalized MG (GMG). However, postoperative myasthenic crisis (POMC) is a serious post-thymectomy complication. Preoperative anxiety (POA) is common but typically neglected in MG patients. The association of POA with POMC has not yet been examined.From June 2007 to December 2013, 541 cases of MG were admitted to the First Affiliated Hospital of Sun Yat-sen University (Guangzhou, China). All cases underwent extended transsternal thymectomy (ETT). The clinical and pathological characteristics of these patients, including POA and POMC, were analyzed.A total of 179 patients experienced POA and 67 patients experienced POMC. Patients with POA were more likely to have POMC, a thymoma, and an ectopic thymus. Univariate analysis showed that POMC correlated with POA, presence of an ectopic thymus, dose of pyridostigmine bromide (PYR), presence of a thymoma, MGFA stage, preoperative myasthenic crisis, and postoperative pneumonia. Multivariate logistic regression analysis showed that the independent risk factors for POMC were POA, preoperative myasthenic crisis, higher dose of PYR, and postoperative pneumonia.Our results suggest that clinicians should consider the risk factors for POMC-especially preoperative anxiety-before performing a thymectomy in patients with MG.
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Affiliation(s)
- Jianyong Zou
- From the Department of Thoracic Surgery, the First Affiliated Hospital (JZ, CS, HZ, YL, HL, ZC); Lung Cancer Research Center (JZ, CS, XL, WY, HZ, YL, HL, ZC); Department of Cardiothoracic Surgery of East Division, the First Affiliated Hospital (XL, WY, ZC); Department of Neurology, the First Affiliated Hospital (WL); and Department of Thoracic Surgery, the Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong 519000, China (BZ)
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Exosomes derived from atorvastatin-modified bone marrow dendritic cells ameliorate experimental autoimmune myasthenia gravis by up-regulated levels of IDO/Treg and partly dependent on FasL/Fas pathway. J Neuroinflammation 2016; 13:8. [PMID: 26757900 PMCID: PMC4710023 DOI: 10.1186/s12974-016-0475-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 01/03/2016] [Indexed: 12/20/2022] Open
Abstract
Background Previously, we have demonstrated that spleen-derived dendritic cells (DCs) modified with atorvastatin suppressed immune responses of experimental autoimmune myasthenia gravis (EAMG). However, the effects of exosomes derived from atorvastatin-modified bone marrow DCs (BMDCs) (statin-Dex) on EAMG are still unknown. Methods Immunophenotypical characterization of exosomes from atorvastatin- and dimethylsulfoxide (DMSO)-modified BMDCs was performed by electron microscopy, flow cytometry, and western blotting. In order to investigate whether statin-DCs-derived exosomes (Dex) could induce immune tolerance in EAMG, we administrated statin-Dex, control-Dex, or phosphate-buffered saline (PBS) into EAMG rats via tail vein injection. The tracking of injected Dex and the effect of statin-Dex injection on endogenous DCs were performed by immunofluorescence and flow cytometry, respectively. The number of Foxp3+ cells in thymuses was examined using immunocytochemistry. Treg cells, cytokine secretion, lymphocyte proliferation, cell viability and apoptosis, and the levels of autoantibody were also carried out to evaluate the effect of statin-Dex on EAMG rats. To further investigate the involvement of FasL/Fas in statin-Dex-induced apoptosis, the underlying mechanisms were studied by FasL neutralization assays. Results Our data showed that the systemic injection of statin-Dex suppressed the clinical symptoms of EAMG rats. These statin-Dex had immune regulation functions in immune organs, such as the spleen, thymus, and popliteal and inguinal lymph nodes. Furthermore, statin-Dex exerted their immunomodulatory effects in vivo by decreasing the expression of CD80, CD86, and MHC class II on endogenous DCs. Importantly, the therapeutic effects of statin-Dex on EAMG rats were associated with up-regulated levels of indoleamine 2,3-dioxygenase (IDO)/Treg and partly dependent on FasL/Fas pathway, which finally resulted in decreased synthesis of anti-R97–116 IgG, IgG2a, and IgG2b antibodies. Conclusions Our data suggest that atorvastatin-induced immature BMDCs are able to secrete tolerogenic Dex, which are involved in the suppression of immune responses in EAMG rats. Importantly, our study provides a novel cell-free approach for the treatment of autoimmune diseases.
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Li X, Mao YT, Wu JJ, Li LX, Chen XJ. Anti-AMPA receptor encephalitis associated with thymomatous myasthenia gravis. J Neuroimmunol 2015; 281:35-7. [DOI: 10.1016/j.jneuroim.2015.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 01/01/2015] [Accepted: 02/28/2015] [Indexed: 01/17/2023]
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Heldal AT, Eide GE, Romi F, Owe JF, Gilhus NE. Repeated acetylcholine receptor antibody-concentrations and association to clinical myasthenia gravis development. PLoS One 2014; 9:e114060. [PMID: 25464006 PMCID: PMC4252099 DOI: 10.1371/journal.pone.0114060] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 11/03/2014] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION We aimed to examine the longitudinal association between Myasthenia Gravis (MG) clinical severity and concentration of acetylcholine receptor (AChR)-antibodies to evaluate if AChR-antibody variations correlate to disease severity. A positive AChR-antibody test is specific for MG. MATERIAL AND METHODS All patients from western Norway who had two or more AChR- antibody tests in the period 1983-2013 were identified. The Myasthenia Gravis Foundation of America (MGFA) Clinical Classification was used to grade disease development. Multiple ordinal logistic regression analysis was used to estimate a possible predictive effect for AChR-antibody concentration on MGFA classification result. RESULTS In 67 patients two or more AChR-antibody tests with a corresponding MGFA-score were performed, with a total of 309 tests. 56 patients were treated with immunosuppressive drugs and 11 by pyridostigmine only. There was a positive association between concentration of AChR-antibodies and longitudinal MGFA-score for the subgroup with immunosuppressive treatment, but not for those treated with pyridostigmine only. This association between AChR-antibody concentration and MGFA score declined with increasing time since onset (p = 0.005 for the interaction of group×time×concentration). CONCLUSIONS For MG patients with immunosuppressive treatment, repeated AChR-antibody measurements give information about clinical development, and can therefore be of support in therapeutic decisions.
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Affiliation(s)
| | - Geir Egil Eide
- Centre of Clinical Research, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Fredrik Romi
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Jone Furlund Owe
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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Berger M, McCallus DE, Lin CSY. Rapid and reversible responses to IVIG in autoimmune neuromuscular diseases suggest mechanisms of action involving competition with functionally important autoantibodies. J Peripher Nerv Syst 2014; 18:275-96. [PMID: 24200120 PMCID: PMC4285221 DOI: 10.1111/jns5.12048] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Intravenous immunoglobulin (IVIG) is widely used in autoimmune neuromuscular diseases whose pathogenesis is undefined. Many different effects of IVIG have been demonstrated in vitro, but few studies actually identify the mechanism(s) most important in vivo. Doses and treatment intervals are generally chosen empirically. Recent studies in Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy show that some effects of IVIG are readily reversible and highly dependent on the serum IgG level. This suggests that in some autoantibody-mediated neuromuscular diseases, IVIG directly competes with autoantibodies that reversibly interfere with nerve conduction. Mechanisms of action of IVIG which most likely involve direct competition with autoantibodies include: neutralization of autoantibodies by anti-idiotypes, inhibition of complement deposition, and increasing catabolism of pathologic antibodies by saturating FcRn. Indirect immunomodulatory effects are not as likely to involve competition and may not have the same reversibility and dose-dependency. Pharmacodynamic analyses should be informative regarding most relevant mechanism(s) of action of IVIG as well as the role of autoantibodies in the immunopathogenesis of each disease. Better understanding of the role of autoantibodies and of the target(s) of IVIG could lead to more efficient use of this therapy and better patient outcomes.
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Affiliation(s)
- Melvin Berger
- Departments of Pediatrics and Pathology, Case Western Reserve University, Cleveland, OH, USA; Immunology Research and Development, CSL Behring, LLC, King of Prussia, PA, USA
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Gur-Wahnon D, Mizrachi T, Wald-Altman S, Higazi AAR, Brenner T. Tissue plasminogen activator involvement in experimental autoimmune myasthenia gravis: Aggravation and therapeutic potential. J Autoimmun 2014; 52:36-43. [DOI: 10.1016/j.jaut.2013.12.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 12/12/2013] [Indexed: 02/01/2023]
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Cejvanovic S, Vissing J. Muscle strength in myasthenia gravis. Acta Neurol Scand 2014; 129:367-73. [PMID: 24117241 DOI: 10.1111/ane.12193] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Myasthenia gravis (MG) is characterized by fatigue and fluctuating muscle weakness as a result of impaired neuromuscular transmission (NMT). Although MG is a prototypic fatiguing disorder, little is known about how the condition affects fixed weakness, and if present, whether weakness is related to disease duration or gender. The aim of this study was to quantify the strength of patients with MG and investigate whether it is related to disease duration. METHODS Eight muscle groups were tested by manual muscle testing and with a hand-held dynamometer in 38 patients with generalized MG and 37 healthy age- and gender-matched controls. The disease duration was recorded and compared with strength measures. RESULTS On average, muscle strength was decreased by 28% compared with controls (P<0.01). Repeated strength measures in individual patients did not differ, suggesting that the muscle force reported was not subject to fatigue, but reflected fixed weakness. The male patients showed a greater reduction in muscle force in all eight muscle groups than women with MG (60% vs 77% of normal, P<0.05). In both men and women with MG, strength in shoulder abductors was most affected (51% vs 62% of normal). Muscle strength and disease duration were not related. CONCLUSIONS These findings show that patients with generalized MG have (i) a significant generalized, fixed muscle weakness, (ii) that male patients with MG have a more severe muscle weakness than women, (iii) that proximal upper limb muscles are most affected, and (iv) that disease duration alone is not a predictor of loss of muscle strength.
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Affiliation(s)
- S. Cejvanovic
- Neuromuscular Research Unit and Department of Neurology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - J. Vissing
- Neuromuscular Research Unit and Department of Neurology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Zhang B, Shen C, Bealmear B, Ragheb S, Xiong WC, Lewis RA, Lisak RP, Mei L. Autoantibodies to agrin in myasthenia gravis patients. PLoS One 2014; 9:e91816. [PMID: 24632822 PMCID: PMC3954737 DOI: 10.1371/journal.pone.0091816] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 02/02/2014] [Indexed: 11/19/2022] Open
Abstract
To determine if patients with myasthenia gravis (MG) have antibodies to agrin, a proteoglycan released by motor neurons and is critical for neuromuscular junction (NMJ) formation, we collected serum samples from 93 patients with MG with known status of antibodies to acetylcholine receptor (AChR), muscle specific kinase (MuSK) and lipoprotein-related 4 (LRP4) and samples from control subjects (healthy individuals and individuals with other diseases). Sera were assayed for antibodies to agrin. We found antibodies to agrin in 7 serum samples of MG patients. None of the 25 healthy controls and none of the 55 control neurological patients had agrin antibodies. Two of the four triple negative MG patients (i.e., no detectable AChR, MuSK or LRP4 antibodies, AChR-/MuSK-/LRP4-) had antibodies against agrin. In addition, agrin antibodies were detected in 5 out of 83 AChR+/MuSK-/LRP4- patients but were not found in the 6 patients with MuSK antibodies (AChR-/MuSK+/LRP4-). Sera from MG patients with agrin antibodies were able to recognize recombinant agrin in conditioned media and in transfected HEK293 cells. These sera also inhibited the agrin-induced MuSK phosphorylation and AChR clustering in muscle cells. Together, these observations indicate that agrin is another autoantigen in patients with MG and agrin autoantibodies may be pathogenic through inhibition of agrin/LRP4/MuSK signaling at the NMJ.
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Affiliation(s)
- Bin Zhang
- Department of Neuroscience and Regenerative Medicine and Department of Neurology, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, United States of America
- Department of Physiology, Basic Medical School, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, P. R. China
| | - Chengyong Shen
- Department of Neuroscience and Regenerative Medicine and Department of Neurology, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, United States of America
- Charlie Norwood VA Medical Center, Augusta, Georgia, United States of America
| | - Beverly Bealmear
- Department of Neurology, School of Medicine, Wayne State University, Detroit, Michigan, United States of America
| | - Samia Ragheb
- Department of Neurology, School of Medicine, Wayne State University, Detroit, Michigan, United States of America
- Department of Biomedical Sciences, Oakland University William Beaumont School of Medicine, Rochester, Michigan, United States of America
| | - Wen-Cheng Xiong
- Department of Neuroscience and Regenerative Medicine and Department of Neurology, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, United States of America
- Charlie Norwood VA Medical Center, Augusta, Georgia, United States of America
| | - Richard A. Lewis
- Department of Neurology, School of Medicine, Wayne State University, Detroit, Michigan, United States of America
- Department of Neurology, Cedars-Sinai Medical Center, West Hollywood, California, United States of America
| | - Robert P. Lisak
- Department of Neurology, School of Medicine, Wayne State University, Detroit, Michigan, United States of America
- Department of Immunology and Microbiology, School of Medicine, Wayne State University, Detroit, Michigan, United States of America
| | - Lin Mei
- Department of Neuroscience and Regenerative Medicine and Department of Neurology, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, United States of America
- Charlie Norwood VA Medical Center, Augusta, Georgia, United States of America
- * E-mail:
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Human immunoglobulin G reduces the pathogenicity of aquaporin-4 autoantibodies in neuromyelitis optica. Exp Neurol 2014; 255:145-53. [PMID: 24636863 DOI: 10.1016/j.expneurol.2014.03.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 02/20/2014] [Accepted: 03/04/2014] [Indexed: 12/14/2022]
Abstract
Neuromyelitis optica (NMO) pathogenesis involves binding of anti-aquaporin-4 (AQP4) autoantibodies (NMO-IgG) present in serum to AQP4 on astrocytes, which causes complement-dependent cytotoxicity (CDC) and antibody-dependent cellular cytotoxicity (ADCC). Human immunoglobulin G (hIgG) is effective for treatment of humorally mediated neurological autoimmune diseases and has been reported to improve disease outcome in a limited number of NMO patients. Here, we investigated hIgG actions on NMO-IgG pathogenicity using an in vivo rat model of NMO and in vitro assays. In rats administered NMO-IgG by intracerebral injection, the size of neuroinflammatory demyelinating lesions was reduced by ~50% when hIgG was administered by intraperitoneal injection to reach levels of 10-25mg/mL in rat serum, comparable with human therapeutic levels. In vitro, hIgG at 10mg/mL reduced by 90% NMO-IgG-mediated CDC following addition of NMO-IgG and human complement to AQP4-expressing cells. The hIgG effect was mainly on the classical complement pathway. hIgG at 10mg/mL also reduced by up to 90% NMO-IgG-mediated ADCC as assayed with human natural killer cells as effector cells. However, hIgG at up to 40mg/mL did not affect AQP4 cell surface expression or its supramolecular assembly in orthogonal arrays of particles, nor did it affect NMO-IgG binding to AQP4. We conclude that hIgG reduces NMO-IgG pathogenicity by inhibition of CDC and ADCC, providing a mechanistic basis to support further clinical evaluation of its therapeutic efficacy in NMO.
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Shenqi fuzheng injection alleviates the transient worsening caused by steroids pulse therapy in treating myasthenia gravis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:816829. [PMID: 24348721 PMCID: PMC3853041 DOI: 10.1155/2013/816829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 10/11/2013] [Accepted: 10/15/2013] [Indexed: 11/18/2022]
Abstract
Purpose. To evaluate the treatment effect and side effect of Shenqi Fuzheng Injection (SFI) on alleviating transient worsening of myasthenia gravis (MG) symptoms caused by high-dose steroids pulse therapy. Methods. Sixty-six consecutive patients with MG were randomly divided into two groups: the treatment group treated with SFI and methylprednisolone pulse therapy (MPT) and the control group treated with MPT alone. The severity of MG before, during, and after MPT and the duration of transient worsening (TW) were evaluated and compared with the clinical absolute scoring (AS) and relative scoring (RS) system. Results. Twenty-nine patients experienced TW in each group. At TW, the AS was significantly increased (P < 0.000) in both groups compared with baseline data, with the AS increase in the treatment group (16.8 ± 2) significantly smaller (P < 0.05) than in the control group (24.9 ± 2.5). At the end of the treatment course, the AS for the treatment group was significantly decreased (7.5 ± 0.9) compared with at TW, although no significant difference compared with the control (9.7 ± 1.1). The TW lasted 1-6 days (mean 3.7) for the treatment group, significantly shorter (P < 0.05) than 2-12 days (mean 7.8) for the control. The RS for the treatment group at the end of treatment was 43.8%-100% (mean 76.8% ± 2.6%), significantly better than the control group: 33.3%-100% (mean 67.2 ± 3.6%). Slight side effects (18.75%) included maldigestion and rash in the treatment group. Conclusion. SFI has a better treatment effect and few side effects and can alleviate the severity and shorten the duration of the transient worsening of MG during steroids pulse therapy.
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Myasthenia gravis and stroke in the setting of giant cell arteritis. Case Rep Rheumatol 2013; 2013:505686. [PMID: 23781375 PMCID: PMC3679761 DOI: 10.1155/2013/505686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 05/04/2013] [Indexed: 11/17/2022] Open
Abstract
This case report concerns the diagnosis of two independent chronic diseases in a patient hospitalized for stroke, myasthenia gravis (MG) and giant cell arteritis (GCA). MG has been found to be associated with several diseases, but there are very few cases documenting its coexistence with GCA. We report the case of a 79-year-old woman initially hospitalized for stroke. Patient's concurrent symptoms of blepharoptosis, dysphagia, and proximal muscle weakness were strongly suggestive of myasthenia gravis. The persistent low-grade fever and elevated inflammatory markers in combination with the visual deterioration that developed also raised the suspicion of GCA. Histological examination confirmed GCA, while muscle acetylcholine receptor antibodies were also present. Even though in medicine one strives to interpret a patient's symptoms with one diagnosis, when one entity cannot fully interpret the clinical and laboratory findings, clinicians must consider the possibility of a second coexisting illness.
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Abstract
PURPOSE OF REVIEW To review ocular myasthenia gravis (OMG), a localized form of myasthenia gravis clinically involving only the extraocular, levator palpebrae superioris, and orbicularis oculi muscles. RECENT FINDINGS Ocular manifestations can masquerade as a variety of ocular motility disorders, including central nervous system disorders and peripheral cranial nerve palsies. While sparing the pupils, the diagnosis and management can be challenging. SUMMARY Because several diagnostic and treatment options are available for OMG, clinicians must decide the sequence and combination based on the level of disease activity and patient disability.
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Li XL, Liu Y, Cao LL, Li H, Yue LT, Wang S, Zhang M, Li XH, Dou YC, Duan RS. Atorvastatin-modified dendritic cells in vitro ameliorate experimental autoimmune myasthenia gravis by up-regulated Treg cells and shifted Th1/Th17 to Th2 cytokines. Mol Cell Neurosci 2013; 56:85-95. [PMID: 23541702 DOI: 10.1016/j.mcn.2013.03.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Revised: 01/25/2013] [Accepted: 03/11/2013] [Indexed: 10/27/2022] Open
Abstract
Conventional therapies for autoimmune diseases produce nonspecific immune suppression, which are usually continued lifelong to maintain disease control, and associated with a variety of adverse effects. In this study, we found that spleen-derived dendritic cells (DCs) from the ongoing experimental autoimmune myasthenia gravis (EAMG) rats can be induced into tolerogenic DCs by atorvastatin in vitro. Administration of these tolerogenic DCs to EAMG rats on days 5 and 13 post immunization (p.i.) resulted in improved clinical symptoms, which were associated with increased numbers of CD4(+)CD25(+) T regulatory (Treg) cells and Foxp3 expression, decreased lymphocyte proliferation among lymph node mononuclear cells (MNC), shifted cytokine profile from Th1/Th17 to Th2 type cytokines, decreased level of anti-R97-116 peptide (region 97-116 of the rat acetylcholine receptor α subunit) IgG antibody in serum. These tolerogenic DCs can migrate to spleen, thymus, popliteal and inguinal lymph nodes after they were injected into the EAMG rats intraperitoneally. Furthermore, these tolerogenic DCs played their immunomodulatory effects in vivo mainly by decreased expression of CD86 and MHC class II on endogenous DCs. All these data provided us a new strategy to treat EAMG and even human myasthenia gravis (MG).
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Affiliation(s)
- Xiao-Li Li
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, PR China
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