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Vinciguerra C, Bevilacqua L, Lupica A, Ginanneschi F, Piscosquito G, Rini N, Rossi A, Barone P, Brighina F, Di Stefano V. Diagnosis and Management of Seronegative Myasthenia Gravis: Lights and Shadows. Brain Sci 2023; 13:1286. [PMID: 37759888 PMCID: PMC10526522 DOI: 10.3390/brainsci13091286] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/30/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
Myasthenia gravis (MG) is an antibody-mediated neuromuscular disease affecting the neuromuscular junction. In most cases, autoantibodies can be detected in the sera of MG patients, thus aiding in diagnosis and allowing for early screening. However, there is a small proportion of patients who have no detectable auto-antibodies, a condition termed "seronegative MG" (SnMG). Several factors contribute to this, including laboratory test inaccuracies, decreased antibody production, immunosuppressive therapy, immunodeficiencies, antigen depletion, and immune-senescence. The diagnosis of SnMG is more challenging and is based on clinical features and neurophysiological tests. The early identification of these patients is needed in order to ensure early treatment and prevent complications. This narrative review aims to examine the latest updates on SnMG, defining the clinical characteristics of affected patients, diagnostic methods, management, and therapeutic scenarios.
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Affiliation(s)
- Claudia Vinciguerra
- Neurology Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84131 Salerno, Italy; (C.V.)
| | - Liliana Bevilacqua
- Neurology Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84131 Salerno, Italy; (C.V.)
| | - Antonino Lupica
- Neurology Unit, Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy (V.D.S.)
| | - Federica Ginanneschi
- Department of Medical, Surgical and Neurological Sciences, University of Siena, 53100 Siena, Italy; (F.G.)
| | - Giuseppe Piscosquito
- Neurology Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84131 Salerno, Italy; (C.V.)
| | - Nicasio Rini
- Neurology Unit, Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy (V.D.S.)
| | - Alessandro Rossi
- Department of Medical, Surgical and Neurological Sciences, University of Siena, 53100 Siena, Italy; (F.G.)
| | - Paolo Barone
- Neurology Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84131 Salerno, Italy; (C.V.)
| | - Filippo Brighina
- Neurology Unit, Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy (V.D.S.)
| | - Vincenzo Di Stefano
- Neurology Unit, Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90127 Palermo, Italy (V.D.S.)
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Yamaguchi Y, Fujimoto T, Hayashi N, Torimura D, Maeda Y, Tsujino A. [A case of elderly-onset myasthenia gravis mimicking stroke with dysarthria and left upper extremity paresis]. Rinsho Shinkeigaku 2021; 61:234-238. [PMID: 33762493 DOI: 10.5692/clinicalneurol.cn-001523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An 80-year-old woman presented with sudden-onset dysarthria and left-side dominant quadriparesis and transferred to our hospital. A neurologic examination revealed slurred speech, prominent left upper extremity weakness and mild weakness of the other extremities. Brain MRI revealed a history of right-side cerebral artery bypass surgery, but no new lesions indicative of stroke. Left upper extremity weakness had improved soon after admission, so a transient ischemic attack was suspected. After admission, the dysarthria fluctuated. The patient's respiratory condition deteriorated several days later and she required ventilation support. Assessment of the cause of the respiratory failure revealed positive muscle-specific kinase (MuSK) antibodies, which suggested myasthenia gravis (MG). The symptoms gradually improved with immunotherapy and we were able to completely withdraw her from the ventilator after a few months. There were some reports that dysphagia and dysarthria present suddenly like stroke without fluctuation of symptoms in elderly-onset MG. It is necessary to note that MG diagnosis may be difficult if elderly patients have multiple comorbidities and unclear diurnal fluctuations.
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Affiliation(s)
| | | | - Nobutaka Hayashi
- Department of Neurology, Sasebo City General Hospital.,Department of Neurology and Strokology, Nagasaki University Hospital
| | | | | | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital
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Elnazeir M, Narayanan S, Badugu P, Hussain A, Tareen T, Hernandez AR, Liu W, Palade AE, Brown ME. Myasthenia Gravis Masquerading as an Idiopathic Unilateral Facial Paralysis (Bell's Palsy)-A Very Rare and Unique Clinical Find. Front Neurol 2020; 11:709. [PMID: 32849192 PMCID: PMC7399091 DOI: 10.3389/fneur.2020.00709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 06/10/2020] [Indexed: 01/28/2023] Open
Abstract
Myasthenia gravis (MG) is an uncommon autoimmune neuromuscular junction disorder manifesting as fluctuating weakness of skeletal muscles. To add to its repertoire of mimicking a wide range of neurological disorders, the present case report is, to the best of our knowledge, the very first to describe MG masquerading as an idiopathic unilateral facial paralysis (Bell's palsy, BP). Our case report is distinct, highlights a novel clinical occurrence, offers new insights of how different neurological disorders may overlap with each other, and reminds neurologists to have a very broad and thorough comprehension for effective diagnoses and treatment plans. Several other conditions that produce facial nerve palsy identical to BP have also been discussed.
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Affiliation(s)
- Marwa Elnazeir
- Department of Neurology, University of Louisville, Louisville, KY, United States
| | - Siddharth Narayanan
- Department of Surgery, University of Louisville, Louisville, KY, United States
| | - Pradeepthi Badugu
- Department of Medicine, University of Louisville, Louisville, KY, United States
| | - Abid Hussain
- Department of Surgery, University of Louisville, Louisville, KY, United States
| | - Tamour Tareen
- Department of Neurology, University of Louisville, Louisville, KY, United States
| | - Alexi R Hernandez
- Department of Neurology, University of Louisville, Louisville, KY, United States
| | - Wei Liu
- Department of Neurology, University of Louisville, Louisville, KY, United States
| | - Adriana E Palade
- Department of Neurology, University of Louisville, Louisville, KY, United States
| | - Martin E Brown
- Department of Neurology, University of Louisville, Louisville, KY, United States
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Hextrum S, Biller J. Clinical Distinction of Cerebral Ischemia and Triaging of Patients in the Emergency Department. Neuroimaging Clin N Am 2018; 28:537-549. [DOI: 10.1016/j.nic.2018.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Park JY, Yang HK, Hwang JM. Diagnostic value of repeated ice tests in the evaluation of ptosis in myasthenia gravis. PLoS One 2017; 12:e0177078. [PMID: 28562609 PMCID: PMC5451013 DOI: 10.1371/journal.pone.0177078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 04/21/2017] [Indexed: 12/04/2022] Open
Abstract
Twenty-six patients with ptosis related to Myasthenia gravis (MG) and 38 controls with ptosis other than MG were included. All patients were tested with the ice test 2 times on separate days in the afternoon. The margin reflex distance (MRD) was measured before and immediately after 2-minute application of ice on the eyelids. The ice test was judged positive if there was an improvement of at least 2.0 mm of MRD after the ice test. Among the patients with negative test results, 'equivocal' was defined by improvement of MRD from at least 1.0 mm to less than 2.0 mm after the ice test. Repeated ice test results showed an agreement of 61.5% in MG, and 97.4% in nonmyasthenic ptosis. Repeated ice tests increased the sensitivity by 34.6% compared to a single test. Among the patients with repeatedly negative test results, 63.6% of those who showed equivocal results at least once turned out to be MG. Of those with repeated non-equivocal negative results, nobody turned out to be MG. There was no significant difference of the ice test results between ocular MG and generalized MG (p = 0.562).
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Affiliation(s)
- Jun Young Park
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Hee Kyung Yang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Jeong-Min Hwang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
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Tremolizzo L, Giopato F, Piatti ML, Rigamonti A, Ferrarese C, Appollonio I. Myasthenia gravis mimicking stroke: a case series with sudden onset dysarthria. Neurol Sci 2015; 36:895-8. [DOI: 10.1007/s10072-015-2098-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 01/27/2015] [Indexed: 12/01/2022]
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