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Theuriet J, Masingue M, Behin A, Ferreiro A, Bassez G, Jaubert P, Tarabay O, Fer F, Pegat A, Bouhour F, Svahn J, Petiot P, Jomir L, Chauplannaz G, Cornut-Chauvinc C, Manel V, Salort-Campana E, Attarian S, Fortanier E, Verschueren A, Kouton L, Camdessanché JP, Tard C, Magot A, Péréon Y, Noury JB, Minot-Myhie MC, Perie M, Taithe F, Farhat Y, Millet AL, Cintas P, Solé G, Spinazzi M, Esselin F, Renard D, Sacconi S, Ezaru A, Malfatti E, Mallaret M, Magy L, Diab E, Merle P, Michaud M, Fournier M, Pakleza AN, Chanson JB, Lefeuvre C, Laforet P, Richard P, Sternberg D, Villar-Quiles RN, Stojkovic T, Eymard B. Congenital myasthenic syndromes in adults: clinical features, diagnosis and long-term prognosis. Brain 2024:awae124. [PMID: 38696726 DOI: 10.1093/brain/awae124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 03/05/2024] [Accepted: 04/01/2024] [Indexed: 05/04/2024] Open
Abstract
Congenital myasthenic syndromes (CMS) are clinically and genetically heterogeneous diseases caused by mutations affecting neuromuscular transmission. Even if the first symptoms mainly occur during childhood, adult neurologists must confront this challenging diagnosis and manage these patients throughout their adulthood. However, long-term follow-up data from large cohorts of CMS patients are lacking and the long-term prognosis of these patients is largely unknown. We report the clinical features, diagnostic difficulties, and long-term prognosis of a French nationwide cohort of 235 adult patients with genetically confirmed CMS followed in 23 specialized neuromuscular centres. Data were retrospectively analysed. Of the 235 patients, 123 were female (52.3%). The diagnosis was made in adulthood in 139 patients, 110 of whom presented their first symptoms before the age of 18. Mean follow-up time between first symptoms and last visit was 34 years (SD = 15.1). Pathogenic variants were found in 19 disease-related genes. CHRNE-low expressor variants were the most common (23.8%), followed by variants in DOK7 (18.7%) and RAPSN (14%). Genotypes were clustered into four groups according to the initial presentation: ocular group (CHRNE-LE, CHRND, FCCMS), distal group (SCCMS), limb-girdle group (RAPSN, COLQ, DOK7, GMPPB, GFPT1), and a variable-phenotype group (MUSK, AGRN). The phenotypical features of CMS did not change throughout life. Only four genotypes had a proportion of patients requiring intensive care unit (ICU) admission that exceeded 20%: RAPSN (54.8%), MUSK (50%), DOK7 (38.6%) and AGRN (25.0%). In RAPSN and MUSK patients most ICU admissions occurred before age 18 years and in DOK7 and AGRN patients at or after 18 years of age. Different patterns of disease course (stability, improvement and progressive worsening) may succeed one another in the same patient throughout life, particularly in AGRN, DOK7 and COLQ. At the last visit, 55% of SCCMS and 36.3% of DOK7 patients required ventilation; 36.3% of DOK7 patients, 25% of GMPPB patients and 20% of GFPT1 patients were wheelchair-bound; most of the patients who were both wheelchair-bound and ventilated were DOK7 patients. Six patients died in this cohort. The positive impact of therapy was striking, even in severely affected patients. In conclusion, even if motor and/or respiratory deterioration could occur in patients with initially moderate disease, particularly in DOK7, SCCMS and GFPT1 patients, the long-term prognosis for most CMS patients was favourable, with neither ventilation nor wheelchair needed at last visit. CHRNE patients did not worsen during adulthood and RAPSN patients, often severely affected in early childhood, subsequently improved.
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Affiliation(s)
- Julian Theuriet
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
- Service d'ENMG et de pathologies neuromusculaires, centre de référence des maladies neuromusculaires PACA-Réunion-Rhône-Alpes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 69500 Bron, France
- Pathophysiology and Genetics of Neuron and Muscle, CNRS UMR 5261, INSERM U1315, Université Lyon 1, Faculté de Médecine Lyon Est, 69008 Lyon, France
| | - Marion Masingue
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
- Centre de Recherche en Myologie, GH Pitié-Salpêtrière, Sorbonne Université-Inserm UMRS974, 75013 Paris, France
| | - Anthony Behin
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
- Centre de Recherche en Myologie, GH Pitié-Salpêtrière, Sorbonne Université-Inserm UMRS974, 75013 Paris, France
| | - Ana Ferreiro
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
- Centre de Recherche en Myologie, GH Pitié-Salpêtrière, Sorbonne Université-Inserm UMRS974, 75013 Paris, France
- Basic and Translational Myology laboratory, Université Paris Cité, BFA, UMR 8251, CNRS, 75013 Paris, France
| | - Guillaume Bassez
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
- Centre de Recherche en Myologie, GH Pitié-Salpêtrière, Sorbonne Université-Inserm UMRS974, 75013 Paris, France
| | - Pauline Jaubert
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
| | - Oriana Tarabay
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
| | - Frédéric Fer
- Centre de Recherche en Myologie, GH Pitié-Salpêtrière, Sorbonne Université-Inserm UMRS974, 75013 Paris, France
| | - Antoine Pegat
- Service d'ENMG et de pathologies neuromusculaires, centre de référence des maladies neuromusculaires PACA-Réunion-Rhône-Alpes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 69500 Bron, France
- Pathophysiology and Genetics of Neuron and Muscle, CNRS UMR 5261, INSERM U1315, Université Lyon 1, Faculté de Médecine Lyon Est, 69008 Lyon, France
| | - Françoise Bouhour
- Service d'ENMG et de pathologies neuromusculaires, centre de référence des maladies neuromusculaires PACA-Réunion-Rhône-Alpes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 69500 Bron, France
- Pathophysiology and Genetics of Neuron and Muscle, CNRS UMR 5261, INSERM U1315, Université Lyon 1, Faculté de Médecine Lyon Est, 69008 Lyon, France
| | - Juliette Svahn
- Pathophysiology and Genetics of Neuron and Muscle, CNRS UMR 5261, INSERM U1315, Université Lyon 1, Faculté de Médecine Lyon Est, 69008 Lyon, France
- Service de Neurologie, troubles du mouvement et pathologies neuromusculaires, Hôpital Neurologique Pierre-Wertheimer, Hospices Civils de Lyon, Groupement Est, 69500 Bron, France
| | - Philippe Petiot
- Service d'ENMG et de pathologies neuromusculaires, centre de référence des maladies neuromusculaires PACA-Réunion-Rhône-Alpes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 69500 Bron, France
| | - Laurentiu Jomir
- Service d'ENMG et de pathologies neuromusculaires, centre de référence des maladies neuromusculaires PACA-Réunion-Rhône-Alpes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 69500 Bron, France
| | - Guy Chauplannaz
- Service d'ENMG et de pathologies neuromusculaires, centre de référence des maladies neuromusculaires PACA-Réunion-Rhône-Alpes, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Groupement Est, 69500 Bron, France
| | - Catherine Cornut-Chauvinc
- Service de Neurologie clinique et fonctionnelle, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69310 Pierre-Bénite, France
| | - Véronique Manel
- Service de Médecine Physique et Réadaptation Pédiatrique, L'Escale, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Groupement Est, 69500 Bron, France
| | - Emmanuelle Salort-Campana
- Service de pathologies neuromusculaires, Hôpital de la Timone, Assistance Publique des Hôpitaux de Marseille, 13005 Marseille, France
| | - Shahram Attarian
- Service de pathologies neuromusculaires, Hôpital de la Timone, Assistance Publique des Hôpitaux de Marseille, 13005 Marseille, France
| | - Etienne Fortanier
- Service de pathologies neuromusculaires, Hôpital de la Timone, Assistance Publique des Hôpitaux de Marseille, 13005 Marseille, France
| | - Annie Verschueren
- Service de pathologies neuromusculaires, Hôpital de la Timone, Assistance Publique des Hôpitaux de Marseille, 13005 Marseille, France
| | - Ludivine Kouton
- Service de pathologies neuromusculaires, Hôpital de la Timone, Assistance Publique des Hôpitaux de Marseille, 13005 Marseille, France
| | - Jean-Philippe Camdessanché
- Service de neurologie, centre référent pour les maladies neuromusculaires, Hôpital Nord, CHU de Saint Etienne, 42270 Saint-Etienne, France
| | - Céline Tard
- Service de Neurologie, U1172, Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, CHU de Lille, 59000 Lille, France
| | - Armelle Magot
- Centre de référence des Maladies Neuromusculaires AOC, Euro-NMD, Filnemus, Hôtel-Dieu, CHU de Nantes, 44000 Nantes, France
| | - Yann Péréon
- Centre de référence des Maladies Neuromusculaires AOC, Euro-NMD, Filnemus, Hôtel-Dieu, CHU de Nantes, 44000 Nantes, France
| | - Jean-Baptiste Noury
- Inserm, LBAI, UMR1227, Centre de référence des Maladies Neuromusculaires AOC, CHRU de Brest, 29200 Brest, France
| | | | - Maud Perie
- Service de Neurologie, CHU Gabriel Montpied, 63000 Clermont-Ferrand, France
| | - Frederic Taithe
- Service de Neurologie, CHU Gabriel Montpied, 63000 Clermont-Ferrand, France
| | - Yacine Farhat
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
| | - Anne-Laure Millet
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, CHU Charles Nicolle, 76000 Rouen, France
| | - Pascal Cintas
- Service de Neurologie, Centre de référence des Maladies Neuromusculaires, CHU de Toulouse Purpan, 31300 Toulouse, France
| | - Guilhem Solé
- Service de Neurologie et des Maladies Neuromusculaires, Centre de référence des Maladies Neuromusculaires AOC, FILNEMUS, EURO-NMD, Hôpital Pellegrin, CHU de Bordeaux, 33000 Bordeaux, France
| | - Marco Spinazzi
- Service de Neurologie, Centre de référence des Maladies Neuromusculaires, CHU d'Angers, 49100 Angers, France
| | - Florence Esselin
- Service de Neurologie, CHU Gui de Chauliac, 34295 Montpellier, France
| | - Dimitri Renard
- Service de Neurologie, Hôpital Caremeau, CHU de Nîmes, 30900 Nîmes, France
| | - Sabrina Sacconi
- Service de Neurologie: Système nerveux périphérique, Muscle et SLA, Hôpital Pasteur 2, CHU de Nice, 06000 Nice, France
| | - Andra Ezaru
- Service de Neurologie: Système nerveux périphérique, Muscle et SLA, Hôpital Pasteur 2, CHU de Nice, 06000 Nice, France
| | - Edoardo Malfatti
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Hôpital Henry Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris Est Créteil, INSERM, U955, IMRB, 94000 Créteil, France
| | - Martial Mallaret
- Service de Neurologie, CHU de Grenoble, 38700 La Tronche, France
| | - Laurent Magy
- Service de Neurologie, Centre de référence des Maladies Neuromusculaires, Hôpital Dupuytren, CHU de Limoges, 87000 Limoges, France
| | - Eva Diab
- Service de Neurophysiologie Clinique, CHU Amiens Picardie, 80000, Amiens, France
- Unité de Recherche Chimère UR 7516, Université Picardie Jules Verne, 80000 Amiens, France
| | - Philippe Merle
- Service de Neurophysiologie Clinique, CHU Amiens Picardie, 80000, Amiens, France
| | - Maud Michaud
- Service de Neurologie, Centre de référence des Maladies Neuromusculaires Nord/Est/Ile-de-France, CHU de Nancy, 54000 Nancy, France
| | | | - Aleksandra Nadaj Pakleza
- Service de Neurologie, Centre de référence des maladies neuromusculaires Nord/Est/Ile-de-France, CHU de Strasbourg, 67000 Strasbourg, France
- European Reference Network - Neuromuscular Diseases (ERN EURO-NMD)
| | - Jean-Baptiste Chanson
- Service de Neurologie, Centre de référence des maladies neuromusculaires Nord/Est/Ile-de-France, CHU de Strasbourg, 67000 Strasbourg, France
- European Reference Network - Neuromuscular Diseases (ERN EURO-NMD)
| | - Claire Lefeuvre
- Service de Neurologie, Centre de référence des maladies neuromusculaires Nord/Est/Ile-de-France, Hôpital Raymond-Poincaré, Assistance Publique des Hôpitaux de Paris, 92380 Garches, France
| | - Pascal Laforet
- Service de Neurologie, Centre de référence des maladies neuromusculaires Nord/Est/Ile-de-France, Hôpital Raymond-Poincaré, Assistance Publique des Hôpitaux de Paris, 92380 Garches, France
- FHU PHENIX, Université Versailles, Université Paris-Saclay, 78000 Saint-Quentin-en-Yvelines, France
| | - Pascale Richard
- Service de Biochimie Métabolique et Centre de Génétique, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
- Unité Fonctionnelle de Cardiogénétique et Myogénétique Moléculaire et cellulaire, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
| | - Damien Sternberg
- Service de Biochimie Métabolique et Centre de Génétique, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
| | - Rocio-Nur Villar-Quiles
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
- Pathophysiology and Genetics of Neuron and Muscle, CNRS UMR 5261, INSERM U1315, Université Lyon 1, Faculté de Médecine Lyon Est, 69008 Lyon, France
| | - Tanya Stojkovic
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
- Pathophysiology and Genetics of Neuron and Muscle, CNRS UMR 5261, INSERM U1315, Université Lyon 1, Faculté de Médecine Lyon Est, 69008 Lyon, France
| | - Bruno Eymard
- Centre de référence des Maladies Neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hôpital Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, 75013 Paris, France
- Pathophysiology and Genetics of Neuron and Muscle, CNRS UMR 5261, INSERM U1315, Université Lyon 1, Faculté de Médecine Lyon Est, 69008 Lyon, France
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Sivadasan A, Cortel-LeBlanc MA, Cortel-LeBlanc A, Katzberg H. Peripheral nervous system and neuromuscular disorders in the emergency department: A review. Acad Emerg Med 2024; 31:386-397. [PMID: 38419365 DOI: 10.1111/acem.14861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 11/30/2023] [Accepted: 12/21/2023] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Acute presentations and emergencies in neuromuscular disorders (NMDs) often challenge clinical acumen. The objective of this review is to refine the reader's approach to history taking, clinical localization and early diagnosis, as well as emergency management of neuromuscular emergencies. METHODS An extensive literature search was performed to identify relevant studies. We prioritized meta-analysis, systematic reviews, and position statements where possible to inform any recommendations. SUMMARY The spectrum of clinical presentations and etiologies ranges from neurotoxic envenomation or infection to autoimmune disease such as Guillain-Barré Syndrome (GBS) and myasthenia gravis (MG). Delayed diagnosis is not uncommon when presentations occur "de novo," respiratory failure is dominant or isolated, or in the case of atypical scenarios such as GBS variants, severe autonomic dysfunction, or rhabdomyolysis. Diseases of the central nervous system, systemic and musculoskeletal disorders can mimic presentations in neuromuscular disorders. CONCLUSIONS Fortunately, early diagnosis and management can improve prognosis. This article provides a comprehensive review of acute presentations in neuromuscular disorders relevant for the emergency physician.
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Affiliation(s)
- Ajith Sivadasan
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- 360 Concussion Care, Ottawa, Ontario, Canada
| | - Achelle Cortel-LeBlanc
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- 360 Concussion Care, Ottawa, Ontario, Canada
- Division of Neurology, Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Mehnert A, Bershan S, Kollmus-Heege J, Gerischer L, Herdick ML, Hoffmann S, Lehnerer S, Scheibe F, Stascheit F, Stein M, Buchan AM, Meisel A, Aigner A, Mergenthaler P. Identifying patients at risk for myasthenic crisis with hemogram and inflammation-related laboratory parameters - a pilot study. Front Neurol 2024; 15:1297997. [PMID: 38469587 PMCID: PMC10925644 DOI: 10.3389/fneur.2024.1297997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/29/2024] [Indexed: 03/13/2024] Open
Abstract
Background Myasthenia gravis (MG) is a rare autoimmune disease characterized by fatigable weakness of the voluntary muscles and can exacerbate to life-threatening myasthenic crisis (MC), requiring intensive care treatment. Routine laboratory parameters are a cost-effective and widely available method for estimating the clinical outcomes of several diseases, but so far, such parameters have not been established to detect disease progression in MG. Methods We conducted a retrospective analysis of selected laboratory parameters related to inflammation and hemogram for MG patients with MC compared to MG patients without MC. To identify potential risk factors for MC, we applied time-varying Cox regression for time to MC and, as a sensitivity analysis, generalized estimating equations logistic regression for the occurrence of MC at the next patient visit. Results 15 of the 58 examined MG patients suffered at least one MC. There was no notable difference in the occurrence of MC by antibody status or sex. Both regression models showed that higher counts of basophils (per 0.01 unit increase: HR = 1.32, 95% CI = 1.02-1.70), neutrophils (per 1 unit increase: HR = 1.40, 95% CI = 1.14-1.72), potentially leukocytes (per 1 unit increase: HR = 1.15, 95% CI = 0.99-1.34), and platelets (per 100 units increase: HR = 1.54, 95% CI = 0.99-2.38) may indicate increased risk for a myasthenic crisis. Conclusion This pilot study provides proof of the concept that increased counts of basophils, neutrophils, leukocytes, and platelets may be associated with a higher risk of developing MC in patients with MG.
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Affiliation(s)
- Anne Mehnert
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Sivan Bershan
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Jil Kollmus-Heege
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Lea Gerischer
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Meret Luise Herdick
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Sarah Hoffmann
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Sophie Lehnerer
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
- Berlin Institute of Health at Charité, Digital Health Center, Berlin, Germany
| | - Franziska Scheibe
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Frauke Stascheit
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Maike Stein
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Alastair M. Buchan
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Annette Aigner
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Philipp Mergenthaler
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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Stein M, Grittner U, Stegherr R, Gerischer L, Stascheit F, Hoffmann S, Herdick M, Legg D, Marbin D, Meisel A, Lehnerer S. The burden of myasthenia gravis - highlighting the impact on family planning and the role of social support. Front Neurol 2023; 14:1307627. [PMID: 38162439 PMCID: PMC10755901 DOI: 10.3389/fneur.2023.1307627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Background Myasthenia gravis (MG) is a rare autoimmune disease and chronic condition that necessitates specialized care. Patients experience a significant burden of disease affecting various aspects of their lives. The aim of this study was to investigate the impact of MG on family planning, challenges associated with pregnancy, childcare responsibilities and the extent to which MG patients perceive and utilize social support. Methods This analysis used data from our main data of a large cross-sectional study built on a questionnaire-based survey encompassing 1,660 MG patients and members of the German Myasthenia Association (Deutsche Myasthenie Gesellschaft), and focused on sociodemographic, clinical and family planning relevant data points. Results Decisions regarding family planning were significantly impacted for individuals with MG when MG symptoms started either before or during their family planning (men: n = 19 and 29.7%; women: n = 156 and 58.4%). In this subgroup a substantial proportion opted against parenthood due to MG (men: n = 8 and 50.0%; women: n = 54 and 38.0% and/or another n = 12 and 8.4% of female participants encountered partner-related refusals). In the subgroup of female SP with MG starting before or during family planning who have reported ever been pregnant the self-reported miscarriage rate was 29.0% (n = 51). MG patients with medium incomes or moderate disease severity reported lower levels of perceived social support. 42.7% (n = 606) of participants needed assistance in negotiations with health insurers and 28.0% (n = 459) needed support for transportation to medical appointments. Conclusion This study shows a significant impact of MG on family planning decisions, affecting both women and men, and often resulting in life-altering decisions such as voluntary childlessness due to MG. The significance of social support becomes evident as a vital factor, especially when navigating through the healthcare system. Tailored healthcare approaches, organized guidance and comprehensive support is needed to enable informed decision-making and offer assistance for MG patients. Clinical trial registration https://clinicaltrials.gov/study/NCT03979521, Registered 7 June 2019 (retrospectively registered).
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Affiliation(s)
- Maike Stein
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Berlin, Germany
| | - Ulrike Grittner
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Regina Stegherr
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Lea Gerischer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - Frauke Stascheit
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - Sarah Hoffmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - Meret Herdick
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
| | - David Legg
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Derin Marbin
- Department of Psychiatry of University Hospital Charité in St. Hedwig Hospital Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Psychiatry and Neurosciences, Berlin, Germany
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sophie Lehnerer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, NeuroScience Clinical Research Center, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Digital Health Center, Berlin, Germany
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5
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Mukhtiar K, Raza M, Tejani I, Ali F, Ibrahim S. Diagnostic dilemmas and challenges in the management of myasthenia in infants and toddlers: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231211047. [PMID: 38022851 PMCID: PMC10631333 DOI: 10.1177/2050313x231211047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Myasthenia in the infancy and toddler age group is rare and often presents a challenge to treating pediatric neurologists. Our report addresses the challenges encountered when distinguishing myasthenia in infants and toddlers from similar illnesses, as well as the differentiation between congenital myasthenia, transient myasthenia, and autoimmune myasthenia. We present four cases of myasthenia between the ages of 10 and 30 months. The diagnosis and management of these cases were challenging due to the variability in clinical presentation. Four cases of myasthenia were diagnosed, with three having autoimmune myasthenia and one having congenital myasthenic syndrome. One patient initially tested negative for acetylcholine receptor antibodies, but later tested positive after 4 months and had a rare facial diplegia finding. The patient with congenital myasthenic syndrome had a novel genetic mutation, DPAGT1 homozygous variants, and also had false positive acetylcholine receptor antibodies. These cases highlight the importance of genetic testing for all infants and toddlers suspected of having myasthenia.
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Affiliation(s)
- Khairunnisa Mukhtiar
- Department of Pediatrics & Child Health, Section of Pediatric Neurology, Aga Khan University Hospital, Karachi, Pakistan
| | - Mohammad Raza
- Department of Pediatrics & Child Health, Section of Pediatric Neurology, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Farhan Ali
- Department of Pediatrics & Child Health, Section of Pediatric Neurology, Aga Khan University Hospital, Karachi, Pakistan
| | - Shahnaz Ibrahim
- Department of Pediatrics & Child Health, Section of Pediatric Neurology, Aga Khan University Hospital, Karachi, Pakistan
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6
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Giovannini E, Bonasoni MP, D'Aleo M, Tamagnini I, Tudini M, Fais P, Pelotti S. Pembrolizumab-Induced Fatal Myasthenia, Myocarditis, and Myositis in a Patient with Metastatic Melanoma: Autopsy, Histological, and Immunohistochemical Findings-A Case Report and Literature Review. Int J Mol Sci 2023; 24:10919. [PMID: 37446095 DOI: 10.3390/ijms241310919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/15/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) represent a major advance in cancer treatment. The lowered immune tolerance induced by ICIs brought to light a series of immune-related adverse events (irAEs). Pembrolizumab belongs to the ICI class and is a humanized IgG4 anti-PD-1 antibody that blocks the interaction between PD-1 and PD-L1. The ICI-related irAEs involving various organ systems and myocarditis are uncommon (incidence of 0.04% to 1.14%), but they are associated with a high reported mortality. Unlike idiopathic inflammatory myositis, ICI-related myositis has been reported to frequently co-occur with myocarditis. The triad of myasthenia, myositis, and myocarditis must not be underestimated as they can rapidly deteriorate, leading to death. Herein we report a case of a patient with metastatic melanoma who fatally developed myasthenia gravis, myocarditis, and myositis, after a single cycle of pembrolizumab. Considering evidence from the literature review, autopsy, histological, and immunohistochemical investigations on heart and skeletal muscle are presented and discussed, also from a medical-legal perspective.
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Affiliation(s)
- Elena Giovannini
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Maria Paola Bonasoni
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Michele D'Aleo
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Ione Tamagnini
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy
| | - Matteo Tudini
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Paolo Fais
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Susi Pelotti
- Unit of Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
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7
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Brittain G, Coles AJ, Giovannoni G, Muraro PA, Palace J, Petrie J, Roldan E, Scolding NJ, Snowden JA, Sharrack B. Autologous haematopoietic stem cell transplantation for immune-mediated neurological diseases: what, how, who and why? Pract Neurol 2023; 23:139-145. [PMID: 36162855 DOI: 10.1136/pn-2022-003531] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/04/2022]
Abstract
In carefully selected patients, autologous haematopoietic stem cell transplantation (HSCT) is a safe, highly effective and cost-saving treatment modality for treatment-resistant, and potentially treatment-naïve, immune-mediated neurological disorders. Although the evidence base has been growing in the last decade, limited understanding has led to confusion, mistrust and increasing use of health tourism. In this article, we discuss what autologous HSCT is, which immune-mediated conditions can be treated with it, how to select patients, what are the expected outcomes and potential adverse effects, and how cost-effective this treatment is.
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Affiliation(s)
- Gavin Brittain
- Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
| | - Alasdair J Coles
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - G Giovannoni
- Neuroscience and Trauma, Blizard Institute of Cell and Molecular Science, London, UK
| | | | | | - Jennifer Petrie
- Clinical Trials Research Unit, The University of Sheffield, Sheffield, UK
| | - Elisa Roldan
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N J Scolding
- Institute of Clinical Neurosciences, University of Bristol, Bristol, UK
- Department of Neurology, Gloucestershire Royal Hospital, Gloucester, UK
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Basil Sharrack
- Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Sheffield Institute for Translational Neuroscience, The University of Sheffield, Sheffield, UK
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8
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Narita T, Nakane S, Nagaishi A, Minami N, Niino M, Kawaguchi N, Murai H, Kira JI, Shimizu J, Iwasa K, Yoshikawa H, Hatanaka Y, Sonoo M, Shimizu Y, Matsuo H. Immunotherapy for ocular myasthenia gravis: an observational study in Japan. Ther Adv Neurol Disord 2023; 16:17562864231163819. [PMID: 37051222 PMCID: PMC10084546 DOI: 10.1177/17562864231163819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/27/2023] [Indexed: 04/14/2023] Open
Abstract
Background Treatment for ocular myasthenia gravis (OMG) has not yet been well established. Few reports have been published on the clinical practice and outcomes of OMG. Objectives We investigated treatment of OMG and its outcomes in Japan.We investigated treatment of OMG and its outcomes in Japan. Design We performed a retrospective cross-sectional survey of OMG patients from eight hospitals in Japan. Methods Clinical information, including sex, age at onset, initial symptoms, autoantibodies, clinical course, treatment history, complications, and outcomes, was obtained. In addition, we recorded the total number of patients with MG and OMG separately. Results In total, 135 patients with OMG (67 men, 68 women) were included. Treatment of OMG was not simple and involved various immunotherapeutic strategies. Eight patients went into remission spontaneously without immunotherapy. A total of 117 patients showed improvements after treatment, whereas 10 patients showed refractory responses to treatment. Overall outcomes were good; however, symptoms persisted in 60.7% of patients even after treatment. Among 90 patients who received immunotherapy, only two showed a refractory response. Meanwhile, for 45 patients who did not receive immunotherapy, 8 were refractory. Thus, the rate of refractory disease in the group with immunotherapy was significantly lower (p = 0.001, u-test) than in the group without immunotherapy. The proportion of generalized MG patients among all MG cases was low in medical centers where immunotherapy for OMG was frequently performed. Conclusion Although the overall prognosis for patients with OMG was good, symptoms remained in more than half of the patients. Immunotherapy, including corticosteroids, may be beneficial for patients with OMG. Plain language summary Is immunosuppressive therapy beneficial for myasthenia gravis patients with ocular symptoms only? Patients with ocular myasthenia gravis (OMG) have only eye symptoms for more than 2 years. Whether this condition is an initial stage of the disease before eventually progressing to generalized myasthenia gravis (gMG) is still uncertain. Different from gMG, OMG is not life-threatening. But eye symptoms often cause troublesome problems in life. Doctors have treated OMG patients similarly to patients with gMG. There is no standard clinical practice for OMG. In this study, we examined how patients with OMG were treated at eight different specialist centers in Japan. In 135 patients with OMG, 8 patients became symptom free without treatment, 117 patients showed improvements after treatment, whereas 10 patients did not get well. Overall outcomes were good, but symptoms remained in 60.7% of patients even after treatment. Among 90 patients who received one or more immunotherapies, only 2 did not get well. Meanwhile, for 45 patients who did not receive immunotherapy, 8 remained ill. We found that treatment of OMG was not simple and often needed multiple immunotherapies. Administering immunotherapy, including corticosteroids, may be beneficial for patients with OMG.
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Affiliation(s)
| | | | - Akiko Nagaishi
- Department of Neurology, National Hospital Organization, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization, Hokkaido Medical Center, Sapporo, Japan
| | - Masaaki Niino
- Department of Neurology, National Hospital Organization, Hokkaido Medical Center, Sapporo, Japan
| | | | - Hiroyuki Murai
- Department of Neurology, Neurological Institute, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
- Department of Neurology, International University of Health and Welfare, Tokyo, Japan
| | - Jun-ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Jun Shimizu
- Department of Neurology, Tokyo University, Tokyo, Japan
| | - Kazuo Iwasa
- Department of Neurology and Neurobiology of Aging, Kanazawa University, Kanazawa, Japan
| | - Hiroaki Yoshikawa
- Department of Neurology and Neurobiology of Aging, Kanazawa University, Kanazawa, Japan
- Health Service Center, Kanazawa University, Kanazawa, Japan
| | - Yuki Hatanaka
- Department of Neurology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Masahiro Sonoo
- Department of Neurology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Yuko Shimizu
- Department of Neurology, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
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9
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Kovrazhkina EA, Serdyuk AV, Razinskaya OD, Shurdumova MH, Vyatkina NV, Baranova EA. [Myasthenic syndrome in a patient with end-stage amyotrophic lateral sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:102-107. [PMID: 37490673 DOI: 10.17116/jnevro2023123071102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) and myasthenia gravis are diseases with similar clinical features but different prognosis and approach to treatment. It is possible as an extremely rare combination of these diseases, as well as myasthenia gravis with signs of ALS (MuSK-positive), as well as ALS, accompanied by myasthenic syndrome. Latter option is the most common. Myasthenic syndrome accompanying the ALS characterized by pathological muscle fatigue signs, symptoms variability during the day, partial sensitivity to neostigmine, M-wave decrements detection during electromyographyc study. We present a case of a patient with terminal ALS and myasthenic syndrome. The main pathogenesis theories of this condition and the differential diagnosis of ALS and myasthenia gravis are discussed.
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Affiliation(s)
- E A Kovrazhkina
- Federal Center for Brain and Neurotechnology, Moscow, Russia
| | - A V Serdyuk
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - O D Razinskaya
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M H Shurdumova
- Pirogov Russian National Research Medical University, Moscow, Russia
- Moscow City Clinical Hospital No. 31, Moscow, Russia
| | - N V Vyatkina
- Moscow City Clinical Hospital No. 31, Moscow, Russia
| | - E A Baranova
- Federal Center for Brain and Neurotechnology, Moscow, Russia
- Kazan State Medical Academy, Kazan, Russia
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10
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Elwan M, Schaefer AM, Craig K, Hopton S, Falkous G, Blakely EL, Taylor RW, Warren N. Changing faces of mitochondrial disease: autosomal recessive POLG disease mimicking myasthenia gravis and progressive supranuclear palsy. BMJ Neurol Open 2022; 4:e000352. [PMCID: PMC9743281 DOI: 10.1136/bmjno-2022-000352] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
Background Mitochondrial disorders are known to cause diverse neurological phenotypes which cause a diagnostic challenge to most neurologists. Pathogenic polymerase gamma (POLG) variants have been described as a cause of chronic progressive external ophthalmoplegia, which manifests with ptosis, horizontal and vertical eye movement restriction and myopathy. Autosomal dominant progressive external ophthalmoplegia is rarely associated with Parkinsonism responsive to levodopa. Methods We report a case of a 58-year-old man who presented with an eye movement disorder then Parkinsonism who made his way through the myasthenia then the movement disorder clinic. Results A diagnostic right tibialis anterior biopsy revealed classical hallmarks of mitochondrial disease, and genetic testing identified compound heterozygous pathogenic gene variants in the POLG gene. The patient was diagnosed with autosomal recessive POLG disease. Conclusions It is important to maintain a high index of suspicion of pathogenic POLG variants in patients presenting with atypical Parkinsonism and ophthalmoplegia. Patients with POLG-related disease will usually have ptosis, and downgaze is typically preserved until late in the disease. Accurate diagnosis is essential for appropriate prognosis and genetic counselling.
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Affiliation(s)
- Menatalla Elwan
- Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Andrew M Schaefer
- Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne, UK,Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Kate Craig
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Sila Hopton
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Gavin Falkous
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Emma L Blakely
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Robert W Taylor
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK,NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle University, Newcastle upon Tyne, UK
| | - Naomi Warren
- Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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11
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Houston KE, Paschalis EI. Feasibility of Magnetic Levator Prosthesis Frame Customization Using Craniofacial Scans and 3-D Printing. Transl Vis Sci Technol 2022; 11:34. [PMID: 36269183 PMCID: PMC9617505 DOI: 10.1167/tvst.11.10.34] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/22/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose To determine the feasibility of a custom frame generation approach for nonsurgical management of severe blepharoptosis with the magnetic levator prosthesis (MLP). Methods Participants (n = 8) with severe blepharoptosis (obscuring the visual axis) in one or both eyes who had previously been using a non-custom MLP had a craniofacial scan with a smartphone app to generate a custom MLP frame. A magnetic adhesive was attached to the affected eyelid. The custom MLP frame held a cylindrical magnet near the eyebrow above the affected eyelid, suspending it in the magnetic field while still allowing blinking. The spectacle magnet could be rotated manually, providing adjustable force via angular translation of the magnetic field. Fitting success and comfort were recorded, and interpalpebral fissure (IPF) was measured from video frames after 20 minutes in-office and one-week at-home use. Preference was documented, custom versus non-custom. Results Overall, 88% of patients (7/8) were successfully fitted with a median 9/10 comfort (interquartile 7-10) and median ptosis improvement of 2.3 mm (1.3-5.0); P = 0.01). Exact binomial testing suggested, with 80% power, that the true population success rate was significantly greater than 45% (P = 0.05). Five participants took the custom MLP home for one week, with only one case of mild conjunctival redness which resolved without treatment. Highest to lowest force modulation resulted in a marginally significant median IPF adjustment of 1.5 mm (0.8 to 2.7; P = 0.06). All preferred the custom frame. Conclusions The three-dimensional custom MLP frame generation approach using a smartphone app-based craniofacial scan is a feasible approach for clinical deployment of the MLP. Translational Relevance First demonstration of customized frame generation for the MLP.
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Affiliation(s)
- Kevin E. Houston
- Massachusetts Eye and Ear, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Schepens Eye Research Institute, Boston, MA, USA
| | - Eleftherios I. Paschalis
- Massachusetts Eye and Ear, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Schepens Eye Research Institute, Boston, MA, USA
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12
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Yavuz P, Demir OO, Ozsurekci Y, Ozen S, Anlar B, Haliloglu G. New-Onset Ocular Myasthenia after Multisystem Inflammatory Syndrome in Children. J Pediatr 2022; 245:213-216. [PMID: 35231493 PMCID: PMC8882031 DOI: 10.1016/j.jpeds.2022.02.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/13/2022]
Abstract
Neurologic complications have been associated with multisystem inflammatory syndrome in children, possibly involving autoimmune mechanisms. Here, we report a 6-year-old girl who developed myasthenia 11 weeks after severe acute respiratory syndrome coronavirus 2 infection and 8 weeks after the onset of severe multisystem inflammatory syndrome in children.
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Affiliation(s)
- Pınar Yavuz
- Division of Pediatric Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Osman Oguz Demir
- Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Yasemin Ozsurekci
- Division of Pediatric Infectious Diseases, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Seza Ozen
- Division of Pediatric Rheumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Banu Anlar
- Division of Pediatric Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Goknur Haliloglu
- Division of Pediatric Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
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13
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Nelke C, Schroeter CB, Stascheit F, Pawlitzki M, Regner-Nelke L, Huntemann N, Arat E, Öztürk M, Melzer N, Mergenthaler P, Gassa A, Stetefeld H, Schroeter M, Berger B, Totzeck A, Hagenacker T, Schreiber S, Vielhaber S, Hartung HP, Meisel A, Wiendl H, Meuth SG, Ruck T. Eculizumab versus rituximab in generalised myasthenia gravis. J Neurol Neurosurg Psychiatry 2022; 93:548-554. [PMID: 35246490 PMCID: PMC9016243 DOI: 10.1136/jnnp-2021-328665] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/22/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Myasthenia gravis (MG) is the most common autoimmune disorder affecting the neuromuscular junction. However, evidence shaping treatment decisions, particularly for treatment-refractory cases, is sparse. Both rituximab and eculizumab may be considered as therapeutic options for refractory MG after insufficient symptom control by standard immunosuppressive therapies. METHODS In this retrospective observational study, we included 57 rituximab-treated and 20 eculizumab-treated patients with MG to compare the efficacy of treatment agents in generalised, therapy-refractory anti-acetylcholine receptor antibody (anti-AChR-ab)-mediated MG with an observation period of 24 months. Change in the quantitative myasthenia gravis (QMG) score was defined as the primary outcome parameter. Differences between groups were determined in an optimal full propensity score matching model. RESULTS Both groups were comparable in terms of clinical and demographic characteristics. Eculizumab was associated with a better outcome compared with rituximab, as measured by the change of the QMG score at 12 and 24 months of treatment. Minimal manifestation of disease was more frequently achieved in eculizumab-treated patients than rituximab-treated patients at 12 and 24 months after baseline. However, the risk of myasthenic crisis (MC) was not ameliorated in either group. INTERPRETATION This retrospective, observational study provides the first real-world evidence supporting the use of eculizumab for the treatment of refractory, anti-AChR-ab positive MG. Nonetheless, the risk of MC remained high and prompts the need for intensified monitoring and further research effort aimed at this vulnerable patient cohort.
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Affiliation(s)
- Christopher Nelke
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | | | - Frauke Stascheit
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marc Pawlitzki
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany.,Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Liesa Regner-Nelke
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Niklas Huntemann
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Ercan Arat
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Menekse Öztürk
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Nico Melzer
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Philipp Mergenthaler
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Asmae Gassa
- Department of Cardiothoracic Surgery, University Hospital Cologne, Koln, Germany
| | - Henning Stetefeld
- Departement of Neurology, Uniklinik Koln, Koln, Nordrhein-Westfalen, Germany
| | | | - Benjamin Berger
- Department of Neurology and Neurophysiology, University Hospital Freiburg, Freiburg, Germany
| | - Andreas Totzeck
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Stefanie Schreiber
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - Stefan Vielhaber
- Otto von Guericke Universität Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Andreas Meisel
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Heinz Wiendl
- Department of Neurology - Inflammatory Disorders of the Nervous System and Neurooncology, University of Münster, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
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14
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Michail M, Zouvelou V, Belimezi M, Haroniti A, Zouridakis M, Zisimopoulou P. Analysis of nAChR Autoantibodies Against Extracellular Epitopes in MG Patients. Front Neurol 2022; 13:858998. [PMID: 35418927 PMCID: PMC8995881 DOI: 10.3389/fneur.2022.858998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/28/2022] [Indexed: 01/12/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disorder caused by autoantibodies targeting components of the postsynaptic membrane of the neuromuscular junction (NMJ), leading to neuromuscular transmission deficiency. In the vast majority of patients, these autoantibodies target the nicotinic acetylcholine receptor (nAChR), a heteropentameric ion channel anchored to the postsynaptic membrane of the NMJ. Autoantibodies in patients with MG may target all the subunits of the receptor at both their extracellular and intracellular regions. Here, we combine immunoadsorption with a cell-based assay to examine the specificity of the patients' autoantibodies against the extracellular part of the nAChR. Our results reveal that these autoantibodies can be divided into distinct groups, based on their target, with probably different impacts on disease severity. Although our findings are based on a small sample group of patients, they strongly support that additional analysis of the specificity of the autoantibodies of patients with MG could serve as a valuable tool for the clinicians' decision on the treatment strategy to be followed.
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Affiliation(s)
- Maria Michail
- Laboratory of Molecular Neurobiology and Immunology, Hellenic Pasteur Institute, Athens, Greece.,Department of Biology, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasiliki Zouvelou
- Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Belimezi
- Diagnostic Department, Hellenic Pasteur Institute, Athens, Greece
| | - Anna Haroniti
- Laboratory of Molecular Neurobiology and Immunology, Hellenic Pasteur Institute, Athens, Greece
| | - Marios Zouridakis
- Laboratory of Molecular Neurobiology and Immunology, Hellenic Pasteur Institute, Athens, Greece
| | - Paraskevi Zisimopoulou
- Laboratory of Molecular Neurobiology and Immunology, Hellenic Pasteur Institute, Athens, Greece
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15
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Siu DHW, O'Neill RS, Harris CA, Wang J, Ardolino L, Downton T, Tong M, Hong JH, Chin V, Clingan PR, Aghmesheh M, Soudy H. Immune checkpoint inhibitor-induced myocarditis, myositis, myasthenia gravis and transaminitis: a case series and review. Immunotherapy 2022; 14:511-520. [PMID: 35321560 DOI: 10.2217/imt-2021-0225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Immune checkpoint inhibitors have been incorporated into the treatment of various malignancies. An increasing body of literature is reporting rare but potentially fatal adverse events associated with these agents. In this case series, the authors report the clinical features and outcomes of seven patients who received immune checkpoint inhibitors for different solid organ malignancies and developed a tetrad of immune-related myocarditis, myositis, myasthenia gravis and transaminitis. Herein the authors review the literature and describe the current diagnostic and management approach for this overlapping syndrome. The authors' series highlights the importance of a high index of clinical suspicion, prompt comprehensive investigations, early multidisciplinary team involvement and initiation of immunosuppressive therapy when immune-related adverse events are suspected.
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Affiliation(s)
- Derrick Ho Wai Siu
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, 2050, Australia.,Faculty of Medicine, The University of New South Wales, New South Wales, Australia
| | - Robert Sean O'Neill
- Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
| | - Carole A Harris
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
| | - Justine Wang
- Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Neurology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,Institute of Neurological Sciences, Prince of Wales Hospital, Randwick, New South Wales, 2031, Australia
| | - Luke Ardolino
- Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, The Kinghorn Centre, St Vincent's Hospital, Darlinghurst, New South Wales, 2010, Australia
| | - Teesha Downton
- Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia
| | - Matthew Tong
- Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
| | - Jun Hee Hong
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia
| | - Venessa Chin
- Department of Medical Oncology, The Kinghorn Centre, St Vincent's Hospital, Darlinghurst, New South Wales, 2010, Australia.,Single Cell and Computational Genomics Lab, The Garvan Institute of Medical Research, Darlinghurst, New South Wales, 2010, Australia
| | - Philip R Clingan
- Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia.,University of Wollongong, New South Wales, Australia
| | - Morteza Aghmesheh
- Department of Medical Oncology, The Wollongong Hospital, Wollongong, New South Wales, 2500, Australia.,University of Wollongong, New South Wales, Australia
| | - Hussein Soudy
- Department of Medical Oncology, St George Hospital, Kogarah, New South Wales, 2217, Australia.,Faculty of Medicine, The University of New South Wales, New South Wales, Australia.,Department of Medical Oncology, Sutherland Hospital, Caringbah, New South Wales, 2229, Australia
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16
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Figueroa-Perez N, Kashyap R, Bal D, Anjum Khan S, Pattan V. Autoimmune Myasthenia, Primary Adrenal Insufficiency, and Progressive Hypothyroidism Due to Pembrolizumab and Axitinib Combination Regimen. Cureus 2021; 13:e16933. [PMID: 34513503 PMCID: PMC8412885 DOI: 10.7759/cureus.16933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 11/29/2022] Open
Abstract
Immune checkpoint inhibitors (ICI) and tyrosine kinase inhibitors (TKI) have been among the increasingly used antineoplastic agents for advanced cancers including renal cell carcinoma (RCC). Although these antineoplastic agents have broad range of efficacy, rare adverse events - mild and fatal, acute and chronic, immune and non-immune mediated - have been reported. We report a case of a 73-year-old Caucasian male patient with stage IV right-sided clear cell RCC who was treated with a pembrolizumab-axitinib combination regimen and suffered life-threatening, acute onset immune-related myasthenia gravis (MG), subsequently progressive hypothyroidism, and primary adrenal insufficiency.
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Affiliation(s)
| | - Rahul Kashyap
- Internal Medicine/Critical Care, Centennial Medical Center, Hospital Corporation of America (HCA) Healthcare, Nashville, USA
| | - Deepinder Bal
- Internal Medicine, Centennial Medical Center, Hospital Corporation of America (HCA) Healthcare, Nashville, USA
| | - Syed Anjum Khan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, USA
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17
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Agrati C, Di Cosimo S, Fenoglio D, Apolone G, Ciceri F, Ciliberto G, Baldanti F, Costantini M, Giannarelli D, Ippolito G, Locatelli F, Mantovani A, Morrone A, Tagliavini F, Uccelli A, Zinzani PL, Silvestris N, Rescigno M. COVID-19 Vaccination in Fragile Patients: Current Evidence and an Harmonized Transdisease Trial. Front Immunol 2021; 12:704110. [PMID: 34447374 PMCID: PMC8383886 DOI: 10.3389/fimmu.2021.704110] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/12/2021] [Indexed: 01/14/2023] Open
Abstract
Patients diagnosed with malignancy, neurological and immunological disorders, i.e., fragile patients, have been excluded from COVID-19 vaccine trials. However, this population may present immune response abnormalities, and relative reduced vaccine responsiveness. Here we review the limited current evidence on the immune responses to vaccination of patients with different underlying diseases. To address open questions we present the VAX4FRAIL study aimed at assessing immune responses to vaccination in a large transdisease cohort of patients with cancer, neurological and rheumatological diseases.
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Affiliation(s)
- Chiara Agrati
- Cellular Immunology Laboratory, Department of Epidemiology, Preclinical Research and Advanced Diagnostic, National Institute for Infectious Diseases (INMI) Lazzaro Spallanzani - IRCCS, Roma, Italy
| | - Serena Di Cosimo
- Biomarkers Unit, Department of Applied Research and Technological Development, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Daniela Fenoglio
- Department of Internal Medicine and Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
- Biotherapies Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giovanni Apolone
- Scientific Directorate, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Fabio Ciceri
- Scientific Directorate, IRCSS San Raffaele Scientific Institute, Milano, Italy
| | - Gennaro Ciliberto
- IRCCS Regina Elena National Cancer Institute, Istituti Fisioterapici Ospitalieri (IFO), Rome, Italy
| | - Fausto Baldanti
- Molecular Virology Unit, Fondazione IRCCS Policlinico San Matteo; Dpt. of Clinical, Surgical, Diagnostics and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Massimo Costantini
- Scientific Directorate, Azienda Unita Sanitaria Locale (USL)-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Diana Giannarelli
- Biostatistical Unit, Istituto Nazionale Tumori Regina Elena IRCCS - IFO, Rome, Italy
| | - Giuseppe Ippolito
- Scientific Directorate, INMI Lazzaro Spallanzani - IRCCS, Roma, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambino Gesù, Department of Gynecology-Obstetrics and Pediatrics, University “La Sapienza”, Roma, Italy
| | - Alberto Mantovani
- Scientific Directorate, IRCCS Humanitas Clinical and Research Center, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- William Harvey Research Institute, Queen Mary University, London, United Kingdom
| | - Aldo Morrone
- Scientific Directorate, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Fabrizio Tagliavini
- Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Antonio Uccelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health and Center of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia “Seràgnoli”, Bologna, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, Bologna, Italy
| | - Nicola Silvestris
- Medical Oncology Department, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Bari, Italy
| | - Maria Rescigno
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Mucosal Immunology and Microbiota Unit, IRCCS Humanitas Clinical and Research Center, Milano, Italy
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18
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Trillenberg P, Katalinic A, Thern J, Graf T. The risk of worsening of myasthenia by cardiovascular medication as reflected by reporting frequency. Eur J Neurol 2021; 28:2965-2970. [PMID: 34184370 DOI: 10.1111/ene.14996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/31/2021] [Accepted: 06/24/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Some groups of cardiovascular drugs (beta-blocking drugs, Ca antagonists, antiarrhythmics) are listed as potentially worsening myasthenia. An empirical basis for alternative recommendations for antihypertensive and antiarrhythmic therapy in myasthenia patients has not yet been provided. METHODS From the World Health Organization pharmacovigilance database, we retrieved total and myasthenia-related counts of adverse drug reactions for various groups of drugs used in cardiovascular disease and drugs with related mechanism of action used in other indications. We calculated the reporting odds ratio as a measure of a disproportional fraction of myasthenia-related events among all events. A 95% confidence interval of reporting odds ratio (ROR) >1 was taken as an indication for a higher risk. Because our approach involves a considerable number of tests, this situation is referred to as a signal that requires additional confirmation. RESULTS A signal for an increased risk was noted for tizanidine, for alpha-blocking drugs, for beta-blocking drugs, and for Ca antagonists. ROR indicated a lower-than-average risk for salbutamol, angiotensin receptor antagonists, oral anticoagulants, thrombocytic function inhibitors, and heparins. CONCLUSIONS Angiotensin receptor antagonists, angiotensin-converting enzyme inhibitors, and diuretics seem to be safe in antihypertensive therapy. Surprisingly, and yet requiring confirmation by case reports, alpha receptor-blocking drugs seem to carry a risk of myasthenia worsening. Amiodarone seems to be a safe alternative in antiarrhythmic therapy in patients with myasthenia.
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Affiliation(s)
- Peter Trillenberg
- Department of Neurology, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Alexander Katalinic
- Institute of Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
| | - Julia Thern
- Department of Pharmacy, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Tobias Graf
- Department of Cardiology, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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19
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Botta C, Agostino RM, Dattola V, Cianci V, Calandruccio ND, Bianco G, Mafodda A, Maisano R, Iuliano E, Orizzonte G, Mazzacuva D, Falzea AC, Saladino RE, Giannicola R, Restifo G, Aguglia U, Caraglia M, Correale P. Myositis/ Myasthenia after Pembrolizumab in a Bladder Cancer Patient with an Autoimmunity-Associated HLA: Immune-Biological Evaluation and Case Report. Int J Mol Sci 2021; 22:6246. [PMID: 34200673 PMCID: PMC8230397 DOI: 10.3390/ijms22126246] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 02/07/2023] Open
Abstract
Pembrolizumab (mAb to PD-1) has been recently approved for the therapy of pretreated urothelial cancer. Despite the efficacy, it is often accompanied by unpredictable and sometime severe immune-related (ir) adverse events (AEs). Here, we report the clinical and immune-biological characterization of a patient with a metastatic bladder cancer who developed myositis signs (M) and a myasthenia-like syndrome (MLS) during treatment with pembrolizumab. The patient presented an autoimmunity-associated HLA haplotype (HLA-A*02/HLA-B*08/HLA-C*07/HLA-DRB1*03) and experienced an increase in activated CD8 T-cells along the treatment. The symptomatology regressed after pembrolizumab discontinuation and a pyridostigmine and steroids-based therapy. This is the first report of concurrent M and MLS appearance in cancer patients receiving pembrolizumab. More efforts are needed to define early the risk and the clinical meaning of irAEs in this setting.
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Affiliation(s)
- Cirino Botta
- Unit of Hematology, Azienda Ospedaliera “Annunziata”, 87100 Cosenza, Italy
- Hematology Unit, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90128 Palermo, Italy
| | - Rita Maria Agostino
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Vincenzo Dattola
- Unit of Neurology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (V.D.); (V.C.); (U.A.)
| | - Vittoria Cianci
- Unit of Neurology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (V.D.); (V.C.); (U.A.)
| | - Natale Daniele Calandruccio
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Giovanna Bianco
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Antonino Mafodda
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Roberto Maisano
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Eleonora Iuliano
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Giovanna Orizzonte
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Domenico Mazzacuva
- Laboratory of Autoimmunity, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy;
| | - Antonia Consuelo Falzea
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Rita Emilena Saladino
- HLA Tissue Typing Laboratory, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy;
| | - Rocco Giannicola
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
| | - Giorgio Restifo
- Nuclear Medicine Unit, Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy;
| | - Umberto Aguglia
- Unit of Neurology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (V.D.); (V.C.); (U.A.)
| | - Michele Caraglia
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy;
- Laboratory of Precision and Molecular Oncology, Biogem Scarl, Institute of Genetic Research, 83031 Ariano Irpino, Italy
| | - Pierpaolo Correale
- Unit of Oncology, Unit. Grand Metropolitan Hospital “Bianchi Melacrino Morelli”, 89124 Reggio Calabria, Italy; (R.M.A.); (N.D.C.); (G.B.); (A.M.); (R.M.); (E.I.); (G.O.); (A.C.F.); (R.G.)
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20
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Finsterer J, Frank M. Myopathy or Myasthenia Positive for Antibodies Against MuSK, Lrp4, and Titin. Intern Med 2021; 60:1485. [PMID: 33281162 PMCID: PMC8170243 DOI: 10.2169/internalmedicine.6180-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Marlies Frank
- First Medical Department, Municipal Hospital Landstrasse, Austria
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21
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Abstract
The diagnosis of autoimmune Myasthenia Gravis (MG) remains clinical and rests on the history and physical findings of fatigable, fluctuating muscle weakness in a specific distribution. Ancillary bedside tests and laboratory methods help confirm the synaptic disorder, define its type and severity, classify MG according to the causative antibodies, and assess the effect of treatment objectively. We present an update on the tests used in the diagnosis and follow-up of MG and the suggested approach for their application.
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Affiliation(s)
- Rossen T. Rousseff
- Department of Neurology, Ibn-Sina Hospital, Sabah Health Area,, Kuwait City 13115, Kuwait; ; Tel.: +359-878-417-412
- Science and Research Institute, Medical University of Pleven, 5800 Pleven, Bulgaria
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22
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Valencia-Sanchez C, Zekeridou A. Paraneoplastic Neurological Syndromes and Beyond Emerging With the Introduction of Immune Checkpoint Inhibitor Cancer Immunotherapy. Front Neurol 2021; 12:642800. [PMID: 33897597 PMCID: PMC8062756 DOI: 10.3389/fneur.2021.642800] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 12/19/2022] Open
Abstract
Paraneoplastic neurological syndromes are more commonly seen with malignancies such as small cell lung cancer, thymoma, gynecological malignancies, and breast cancer as well as seminoma. With the introduction of immune checkpoint inhibitor (ICI) cancer immunotherapy we see an increase of autoimmune neurological complications in patients with malignancies not traditionally associated with paraneoplastic neurological syndromes, such as melanoma and renal cell carcinoma. Immune checkpoint inhibitors enhance antitumor immune responses resulting often in immune-related adverse effects that can affect any organ, including the central and peripheral nervous system, neuromuscular junction and muscle. Neurological complications are rare; neuromuscular complications are more common than central nervous system ones but multifocal neurological presentations are often encountered. The vast majority of neurological complications appear within 3 months of ICI initiation, but have been described even after ICI cessation. Neural autoantibody testing reveals autoantibodies in approximately half of the patients with CNS complications. Early suspicion and diagnosis is critical to avoid worsening and improve outcomes. Therapeutic strategies depend on the severity of the symptoms and initially typically involve discontinuation of ICI and high dose steroids. Further immunosuppression might be necessary. Outcomes are dependent on patient's characteristics and clinical presentations.
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Affiliation(s)
- Cristina Valencia-Sanchez
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - Anastasia Zekeridou
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, United States
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23
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Abstract
With interest we read the article by Assini et al, about a 77 years old male who developed ptosis, diplopia, dysarthria, and chewing difficulty 2 months after a mild infection with SARS-CoV-2, manifesting with fever and bilateral pneumonia (COVID-19) without necessitating continuous positive airway pressure (CPAP), bilevel positive airway pressure (BIPAP), or mechanical ventilation [1] Work-up revealed muscle-specific tyrosine-kinase (MuSK) positive myasthenia gravis (MG) (MuSK-MG), which did not respond to pyridostigmin but to azathioprine [1]. We have the following comments and concerns.
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Affiliation(s)
| | - Fulvio Alexandre Scorza
- Disciplina de Neurociência, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), São Paulo, Brasil
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24
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Phua CS, Murad A, Fraser C, Bray V, Cappelen-Smith C. Myasthenia gravis and concurrent myositis following PD-L1 checkpoint inhibitor for non-small cell lung cancer. BMJ Neurol Open 2021; 2:e000028. [PMID: 33681778 PMCID: PMC7871726 DOI: 10.1136/bmjno-2019-000028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2020] [Indexed: 11/04/2022] Open
Abstract
Background There are increasing reports of myasthenia gravis (MG) following oncological treatment with immune checkpoint inhibitors (ICIs). Methods and results A 66-year-old man with stage 3A lung adenocarcinoma was treated with second weekly infusions of durvalumab, a programmed cell death ligand-1 inhibitor, at a dose of 10 mg/kg. After the fourth infusion, he developed diplopia, dyspnoea and constitutional symptoms including headache, weakness and anorexia. 1 month later, he developed dysphagia and dysphonia. Examination showed proximal limb weakness with fatigability. An ice pack test was positive. Blood tests revealed a raised creatine kinase and positive PM-Scl75 antibody. Antititin antibody was strongly positive in the serum and cerebrospinal fluid. Antibodies for acetylcholinesterase receptor and antimuscle-specific kinase were negative. Electromyography showed myopathic changes. The patient was treated with steroids, pyridostigmine, mycophenolate mofetil and intravenous immunoglobulin. Eight weeks after treatment initiation ptosis, eye movements and limb strength were markedly improved and repeat creatine kinase was normal. Conclusion Clinicians using ICIs should have a high index of suspicion for ICI-induced MG and concurrent myositis as disease can be severe and is associated with high mortality rates.
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Affiliation(s)
- Chun Seng Phua
- Department of Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Ari Murad
- Department of Immunology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Clare Fraser
- Department of Ophthalmology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Victoria Bray
- Department of Oncology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
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25
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Trillenberg P, Katalinic A, Junghanns K, Thern J. Worsening of myasthenia due to antiepileptic, antipsychotic, antidepressant, and sedative medication: An estimation of risk based on reporting frequency. Eur J Neurol 2021; 28:2349-2356. [PMID: 33566440 DOI: 10.1111/ene.14773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Many drugs can worsen myasthenia symptoms. The clinician usually relies on cautionary lists compiled according to case reports. We intended to provide a quantitative basis for a risk comparison within the groups of antiepileptic, antidepressant, neuroleptic, and sedative drugs. METHODS We extracted adverse drug reaction (ADR) counts (total and myasthenia related) for drugs from these groups and calculated the reporting odds ratio (ROR) within the drug groups from the World Health Organization pharmacovigilance database. For a given drug, the ROR was increased above 1 if the proportion of myasthenia-related ADRs for this drug was larger than the same proportion for the rest of drugs in that same group. If the 95% confidence interval of ROR was >1, this was taken as a signal for a higher risk of the given drug as compared to the average of the respective group. RESULTS Gabapentin, sertraline, citalopram, lithium, and amisulpride had a signal for the ROR to be increased above 1 within their respective groups. Bupropion, desvenlafaxine, duloxetine, escitalopram, and paroxetine had ROR values <1. For all other drugs, 1 was within the ROR confidence interval. CONCLUSIONS For gabapentin and lithium, the analysis of RORs confirmed case reports and cautionary lists. For a number of antidepressant drugs associated with a higher-than-average risk, no case reports exist substantiating our results. For these drugs, special attention should be paid to this risk. The remarkable difference between citalopram and escitalopram could prompt experimental work to confirm differential influence of the two preparations on neuromuscular transmission.
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Affiliation(s)
- Peter Trillenberg
- Department of Neurology, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Alexander Katalinic
- Institute of Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
| | - Klaus Junghanns
- Department of Psychiatry, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Julia Thern
- Department of Pharmacy, University Hospital of Schleswig-Holstein, Lübeck, Germany
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26
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Affiliation(s)
| | - Fulvio A Scorza
- Disciplina de Neurociência, Escola Paulista de Medicine/Universidade Federal de São Paulo (EPM/UNIFESP), São Paulo, Brazil
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27
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Tan Y, Curragh DS, Selva D. The use of frontalis sling in the management of variable ptosis secondary to congenital myasthenic syndrome. Orbit 2021; 41:386-388. [PMID: 33467958 DOI: 10.1080/01676830.2021.1874425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Congenital myasthenic syndrome (CMS) describes a group of rare inherited disorders caused by impaired neuromuscular transmission at the motor endplate. Common ophthalmic manifestations associated with CMS include ptosis and ophthalmoplegia. A 19-year-old female presented with variable day-to-day ptosis secondary to CMS that was refractory to medical therapy. Bilateral silicone frontalis slings were used to stabilise the upper lid height and reduce fluctuation in severity of ptosis. Blepharoptosis surgery has been performed in patients with chronic myasthenia gravis (MG), but rarely in the setting of CMS. Blepharoptosis surgery in CMS patients with variable ptosis is difficult due to the risk of upsetting the original lid position and developing post-operative exposure keratopathy. Our case demonstrates that the frontalis sling procedure may be considered as an option in the management of variable blepharoptosis secondary to CMS.
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Affiliation(s)
- Yiran Tan
- South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia
| | - David S Curragh
- South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia
| | - Dinesh Selva
- South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia
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28
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Porubsky S, Popovic ZV, Badve S, Banz Y, Berezowska S, Borchert D, Brüggemann M, Gaiser T, Graeter T, Hollaus P, Huettl KS, Kotrova M, Kreft A, Kugler C, Lötscher F, Möller B, Ott G, Preissler G, Roessner E, Rosenwald A, Ströbel P, Marx A. Thymic Hyperplasia with Lymphoepithelial Sialadenitis (LESA)-Like Features: Strong Association with Lymphomas and Non-Myasthenic Autoimmune Diseases. Cancers (Basel) 2021; 13:315. [PMID: 33467055 DOI: 10.3390/cancers13020315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/15/2022] Open
Abstract
Thymic hyperplasia (TH) with lymphoepithelial sialadenitis (LESA)-like features (LESA-like TH) has been described as a tumor-like, benign proliferation of thymic epithelial cells and lymphoid follicles. We aimed to determine the frequency of lymphoma and autoimmunity in LESA-like TH and performed retrospective analysis of cases with LESA-like TH and/or thymic MALT-lymphoma. Among 36 patients (21 males) with LESA-like TH (age 52 years, 32-80; lesion diameter 7.0 cm, 1-14.5; median, range), five (14%) showed associated lymphomas, including four (11%) thymic MALT lymphomas and one (3%) diffuse large B-cell lymphoma. One additional case showed a clonal B-cell-receptor rearrangement without evidence of lymphoma. Twelve (33%) patients (7 women) suffered from partially overlapping autoimmune diseases: systemic lupus erythematosus (n = 4, 11%), rheumatoid arthritis (n = 3, 8%), myasthenia gravis (n = 2, 6%), asthma (n = 2, 6%), scleroderma, Sjögren syndrome, pure red cell aplasia, Grave's disease and anti-IgLON5 syndrome (each n = 1, 3%). Among 11 primary thymic MALT lymphomas, remnants of LESA-like TH were found in two cases (18%). In summary, LESA-like TH shows a striking association with autoimmunity and predisposes to lymphomas. Thus, a hematologic and rheumatologic workup should become standard in patients diagnosed with LESA-like TH. Radiologists and clinicians should be aware of LESA-like TH as a differential diagnosis for mediastinal mass lesions in patients with autoimmune diseases.
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29
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Fazal M, Prentice DA, Kho LK, Fysh E. Nivolumab-associated myositis myocarditis and myasthenia and anti-striated muscle antibodies. Intern Med J 2020; 50:1003-1006. [PMID: 33306231 DOI: 10.1111/imj.14946] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/29/2020] [Accepted: 02/09/2020] [Indexed: 01/10/2023]
Abstract
An 82-year-old man was treated with neo-adjuvant nivolumab (programmed cell death protein 1 or PD-1 inhibitor) for local recurrence of melanoma developed myositis, myocarditis and a myasthenic-like syndrome with a fatal outcome. The occurrence of these three conditions may constitute a new immune checkpoint-induced syndrome. The relevance of the clinical features and the immunology is discussed. This case highlights the special role of anti-striated muscle antibodies as a predictor of mortality.
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Affiliation(s)
- Marium Fazal
- General Medicine Department, St John of God Midland Public Hospital, Perth, Western Australia, Australia
| | - David A Prentice
- General Medicine Department, St John of God Midland Public Hospital, Perth, Western Australia, Australia
| | - Lay K Kho
- Neurology Department, St John of God Midland Public Hospital, Perth, Western Australia, Australia
| | - Edward Fysh
- Respiratory Department, St John of God Midland Public Hospital, Perth, Western Australia, Australia
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30
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van den Bersselaar LR, Snoeck MMJ, Gubbels M, Riazi S, Kamsteeg EJ, Jungbluth H, Voermans NC. Anaesthesia and neuromuscular disorders: what a neurologist needs to know. Pract Neurol 2020:practneurol-2020-002633. [PMID: 33109742 PMCID: PMC8172077 DOI: 10.1136/practneurol-2020-002633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2020] [Indexed: 11/04/2022]
Abstract
Neurologists are often asked for specific advice regarding patients with neuromuscular disease who require general anaesthesia. However, guidelines on specific neuromuscular disorders do not usually include specific guidelines or pragmatic advice regarding (regional and/or general) anaesthesia or procedural sedation. Furthermore, the medical literature on this subject is mostly limited to publications in anaesthesiology journals. We therefore summarise general recommendations and specific advice for anaesthesia in different neuromuscular disorders to provide a comprehensive and accessible overview of the knowledge on this topic essential for clinical neurologists. A preoperative multidisciplinary approach involving anaesthesiologists, cardiologists, chest physicians, surgeons and neurologists is crucial. Depolarising muscle relaxants (succinylcholine) should be avoided at all times. The dose of non-depolarising muscle relaxants must be reduced and their effect monitored. Patients with specific mutations in RYR1 (ryanodine receptor 1) and less frequently in CACNA1S (calcium channel, voltage-dependent, L type, alpha 1S subunit) and STAC3 (SH3 and cysteine rich domain 3) are at risk of developing a life-threatening malignant hyperthermia reaction.
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Affiliation(s)
- Luuk R van den Bersselaar
- Anaesthesiology, Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
- Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, Netherlands
| | - Marc M J Snoeck
- Anaesthesiology, Malignant Hyperthermia Investigation Unit, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Madelief Gubbels
- Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, Netherlands
| | - Sheila Riazi
- Anesthesiology and Pain Medicine, Malignant Hyperthermia Investigation Unit, University of Toronto, Toronto, Canada
| | | | - Heinz Jungbluth
- Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
- Department of Basic and Clinical Neuroscience, IoPPN, King's College, London, UK
- Randall Division for Cell and Molecular Biophysics, Muscle Signalling Section, King's College, London, UK
| | - Nicol C Voermans
- Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, Netherlands
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31
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Cossins J, Webster R, Maxwell S, Rodríguez Cruz PM, Knight R, Llewelyn JG, Shin JY, Palace J, Beeson D. Congenital myasthenic syndrome due to a TOR1AIP1 mutation: a new disease pathway for impaired synaptic transmission. Brain Commun 2020; 2:fcaa174. [PMID: 33215087 PMCID: PMC7660151 DOI: 10.1093/braincomms/fcaa174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/24/2020] [Accepted: 08/12/2020] [Indexed: 02/06/2023] Open
Abstract
Congenital myasthenic syndromes are inherited disorders characterized by fatiguable muscle weakness resulting from impaired signal transmission at the neuromuscular junction. Causative mutations have been identified in genes that can affect the synaptic function or structure. We identified a homozygous frameshift deletion c.127delC, p. Pro43fs in TOR1AIP1 in two siblings with limb-girdle weakness and impaired transmission at the neuromuscular synapse. TOR1AIP1 encodes the inner nuclear membrane protein lamin-associated protein 1. On muscle biopsy from the index case, lamin-associated protein 1 was absent from myonuclei. A mouse model with lamin-associated protein 1 conditionally knocked out in striated muscle was used to analyse the role of lamin-associated protein 1 in synaptic dysfunction. Model mice develop fatiguable muscle weakness as demonstrated by using an inverted screen hang test. Electromyography on the mice revealed a decrement on repetitive nerve stimulation. Ex vivo analysis of hemi-diaphragm preparations showed both miniature and evoked end-plate potential half-widths were prolonged which was associated with upregulation of the foetal acetylcholine receptor γ subunit. Neuromuscular junctions on extensor digitorum longus muscles were enlarged and fragmented, and the number of subsynaptic nuclei was significantly increased. Following these findings, electromyography was performed on cases of other nuclear envelopathies caused by mutations in LaminA/C or emerin, but decrement on repetitive nerve stimulation or other indications of defective neuromuscular transmission were not seen. Thus, this report highlights the first nuclear membrane protein in which defective function can lead to impaired synaptic transmission.
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Affiliation(s)
- Judith Cossins
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DS, UK
| | - Richard Webster
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DS, UK
| | - Susan Maxwell
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DS, UK
| | - Pedro M Rodríguez Cruz
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DS, UK
| | - Ravi Knight
- Department of Clinical Neurology, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - John Gareth Llewelyn
- Neurology Department, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK
| | - Ji-Yeon Shin
- Department of Medicine, Columbia University Medical Centre, New York, NY 10032, USA
| | - Jacqueline Palace
- Department of Clinical Neurology, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - David Beeson
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DS, UK
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32
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Hübers A, Lascano AM, Lalive PH. Management of patients with generalised myasthenia gravis and COVID-19: four case reports. J Neurol Neurosurg Psychiatry 2020; 91:1124-1125. [PMID: 32651248 DOI: 10.1136/jnnp-2020-323565] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/09/2020] [Accepted: 06/23/2020] [Indexed: 01/05/2023]
Affiliation(s)
- Annemarie Hübers
- Department of Clinical Neurosciences, University Hospitals Geneva, Geneve, Switzerland
| | - Agustina M Lascano
- Division of Neurology, University Hospitals of Geneva, Geneva, Switzerland
| | - Patrice H Lalive
- Department of Clinical Neurosciences, Division of Neurology, Unit of Neuroimmunology and Multiple Sclerosis, University Hospitals Geneva, Geneva, Switzerland
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33
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Cetin H, Beeson D, Vincent A, Webster R. The Structure, Function, and Physiology of the Fetal and Adult Acetylcholine Receptor in Muscle. Front Mol Neurosci 2020; 13:581097. [PMID: 33013323 PMCID: PMC7506097 DOI: 10.3389/fnmol.2020.581097] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/13/2020] [Indexed: 12/31/2022] Open
Abstract
The neuromuscular junction (NMJ) is a highly developed synapse linking motor neuron activity with muscle contraction. A complex of molecular cascades together with the specialized NMJ architecture ensures that each action potential arriving at the motor nerve terminal is translated into an action potential in the muscle fiber. The muscle-type nicotinic acetylcholine receptor (AChR) is a key molecular component located at the postsynaptic muscle membrane responsible for the generation of the endplate potential (EPP), which usually exceeds the threshold potential necessary to activate voltage-gated sodium channels and triggers a muscle action potential. Two AChR isoforms are found in mammalian muscle. The fetal isoform is present in prenatal stages and is involved in the development of the neuromuscular system whereas the adult isoform prevails thereafter, except after denervation when the fetal form is re-expressed throughout the muscle. This review will summarize the structural and functional differences between the two isoforms and outline congenital and autoimmune myasthenic syndromes that involve the isoform specific AChR subunits.
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Affiliation(s)
- Hakan Cetin
- Department of Neurology, Medical University of Vienna, Vienna, Austria.,Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - David Beeson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Richard Webster
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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34
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Echaniz-Laguna A, Biancalana V, Nadaj-Pakleza A, Fournier E, Matthews E, Hanna MG, Männikkö R. Homozygous C-terminal loss-of-function Na V1.4 variant in a patient with congenital myasthenic syndrome. J Neurol Neurosurg Psychiatry 2020; 91:898-900. [PMID: 32487525 PMCID: PMC7115925 DOI: 10.1136/jnnp-2020-323173] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/24/2020] [Accepted: 05/02/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Andoni Echaniz-Laguna
- Department of Neurology, APHP, CHU de Bicêtre, Le Kremlin Bicêtre, 94276, France
- French National Reference Center for Rare Neuropathies (NNERF), Le Kremlin Bicêtre, 94276, France
- INSERM U1195 & Paris-Sud University, Le Kremlin Bicêtre, 94276, France
- Corresponding author: Roope MÄNNIKKÖ, PhD, MRC Centre for Neuromuscular Diseases, Department of Molecular Neuroscience, UCL Institute of Neurology, London, WC1N 3BG, UK. , T: +44 2034484208
| | - Valérie Biancalana
- Laboratoire Diagnostic Génétique, CHR, Strasbourg, France
- Institut de Génétique et de Biologie Moleculaire et Cellulaire (IGBMC), INSERM U964, CNRS UMR 7104, Federation de Medecine Translationnelle de Strasbourg, Universite de Strasbourg, Illkirch, France
| | | | - Emmanuel Fournier
- Department of Neurophysiology, APHP, CHU Pitié-Salpetriêrè, 75013 Paris, France
| | - Emma Matthews
- Department of Neuromuscular diseases, UCL Institute of Neurology, London, WC1N 3BG, UK
| | - Michael G. Hanna
- Department of Neuromuscular diseases, UCL Institute of Neurology, London, WC1N 3BG, UK
| | - Roope Männikkö
- Department of Neuromuscular diseases, UCL Institute of Neurology, London, WC1N 3BG, UK
- Corresponding author: Roope MÄNNIKKÖ, PhD, MRC Centre for Neuromuscular Diseases, Department of Molecular Neuroscience, UCL Institute of Neurology, London, WC1N 3BG, UK. , T: +44 2034484208
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35
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Mroczek M, Durmus H, Töpf A, Parman Y, Straub V. Four Individuals with a Homozygous Mutation in Exon 1f of the PLEC Gene and Associated Myasthenic Features. Genes (Basel) 2020; 11:genes11070716. [PMID: 32605089 PMCID: PMC7397187 DOI: 10.3390/genes11070716] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 11/17/2022] Open
Abstract
We identified the known c.1_9del mutation in the PLEC gene in four unrelated females from consanguineous families of Turkish origin. All individuals presented with slowly progressive limb-girdle weakness without any dermatological findings, and dystrophic changes observed in their muscle biopsies. Additionally, the neurological examination revealed ptosis, facial weakness, fatigability, and muscle cramps in all four cases. In two patients, repetitive nerve stimulation showed a borderline decrement and a high jitter was detected in all patients by single-fiber electromyography. Clinical improvement was observed after treatment with pyridostigmine and salbutamol was started. We further characterize the phenotype of patients with limb-girdle muscular dystrophy R17 clinically, by muscle magnetic resonance imaging (MRI) features and by describing a common 3.8 Mb haplotype in three individuals from the same geographical region. In addition, we review the neuromuscular symptoms associated with PLEC mutations and the role of plectin in the neuromuscular junction.
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Affiliation(s)
- Magdalena Mroczek
- John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 3BZ, UK; (M.M.); (A.T.)
| | - Hacer Durmus
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul 34093, Turkey; (H.D.); (Y.P.)
| | - Ana Töpf
- John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 3BZ, UK; (M.M.); (A.T.)
| | - Yesim Parman
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul 34093, Turkey; (H.D.); (Y.P.)
| | - Volker Straub
- John Walton Muscular Dystrophy Research Centre, Translational and Clinical Research Institute, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 3BZ, UK; (M.M.); (A.T.)
- Correspondence: ; Tel.: +44-19124-18762-8655
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36
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Vanhaesebrouck AE, Webster R, Maxwell S, Rodriguez Cruz PM, Cossins J, Wickens J, Liu WW, Cetin H, Cheung J, Ramjattan H, Palace J, Beeson D. β2-Adrenergic receptor agonists ameliorate the adverse effect of long-term pyridostigmine on neuromuscular junction structure. Brain 2020; 142:3713-3727. [PMID: 31633155 PMCID: PMC6892641 DOI: 10.1093/brain/awz322] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/04/2019] [Accepted: 08/26/2019] [Indexed: 01/07/2023] Open
Abstract
Acetylcholine receptor deficiency is the most common form of the congenital myasthenic syndromes, a heterogeneous collection of genetic disorders of neuromuscular transmission characterized by fatiguable muscle weakness. Most patients with acetylcholine receptor deficiency respond well to acetylcholinesterase inhibitors; however, in some cases the efficacy of acetylcholinesterase inhibitors diminishes over time. Patients with acetylcholine receptor deficiency can also benefit from the addition of a β2-adrenergic receptor agonist to their medication. The working mechanism of β2-adrenergic agonists in myasthenic patients is not fully understood. Here, we report the long-term follow-up for the addition of β2-adrenergic agonists for a cohort of patients with acetylcholine receptor deficiency on anticholinesterase medication that demonstrates a sustained quantitative improvement. Coincidently we used a disease model to mirror the treatment of acetylcholine receptor deficiency, and demonstrate improved muscle fatigue, improved neuromuscular transmission and improved synaptic structure resulting from the addition of the β2-adrenergic agonist salbutamol to the anticholinesterase medication pyridostigmine. Following an initial improvement in muscle fatiguability, a gradual decline in the effect of pyridostigmine was observed in mice treated with pyridostigmine alone (P < 0.001). Combination therapy with pyridostigmine and salbutamol counteracted this decline (P < 0.001). Studies of compound muscle action potential decrement at high nerve stimulation frequencies (P < 0.05) and miniature end-plate potential amplitude analysis (P < 0.01) showed an improvement in mice following combination therapy, compared to pyridostigmine monotherapy. Pyridostigmine alone reduced postsynaptic areas (P < 0.001) and postsynaptic folding (P < 0.01). Combination therapy increased postsynaptic area (P < 0.001) and promoted the formation of postsynaptic junctional folds (P < 0.001), in particular in fast-twitch muscles. In conclusion, we demonstrate for the first time how the improvement seen in patients from adding salbutamol to their medication can be explained in an experimental model of acetylcholine receptor deficiency, the most common form of congenital myasthenic syndrome. Salbutamol enhances neuromuscular junction synaptic structure by counteracting the detrimental effects of long-term acetylcholinesterase inhibitors on the postsynaptic neuromuscular junction. The results have implications for both autoimmune and genetic myasthenias where anticholinesterase medication is a standard treatment.
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Affiliation(s)
- An E Vanhaesebrouck
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DS, UK
| | - Richard Webster
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DS, UK
| | - Susan Maxwell
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DS, UK
| | - Pedro M Rodriguez Cruz
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DS, UK.,Department of Clinical Neurology, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Judith Cossins
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DS, UK
| | - James Wickens
- Chemistry Research Laboratory, Department of Chemistry, University of Oxford, Oxford, OX1 3TA, UK
| | - Wei-Wei Liu
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DS, UK
| | - Hakan Cetin
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DS, UK
| | - Jonathan Cheung
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DS, UK
| | - Hayley Ramjattan
- Paediatric Neurology, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Jacqueline Palace
- Department of Clinical Neurology, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - David Beeson
- Neurosciences Group, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DS, UK
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37
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Lee CY, Petkova M, Morales-Gonzalez S, Gimber N, Schmoranzer J, Meisel A, Böhmerle W, Stenzel W, Schuelke M, Schwarz JM. A spontaneous missense mutation in the chromodomain helicase DNA-binding protein 8 (CHD8) gene: a novel association with congenital myasthenic syndrome. Neuropathol Appl Neurobiol 2020; 46:588-601. [PMID: 32267004 DOI: 10.1111/nan.12617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 03/23/2020] [Indexed: 12/13/2022]
Abstract
AIMS Congenital myasthenic syndromes (CMS) are characterized by muscle weakness, ptosis and episodic apnoea. Mutations affect integral protein components of the neuromuscular junction (NMJ). Here we searched for the genetic basis of CMS in female monozygotic twins. METHODS We employed whole-exome sequencing for mutation detection and Sanger sequencing for segregation analysis. Immunohistology was done with antibodies against CHD8, rapsyn, β-catenin (βCAT) and golgin on fi-bro-blasts, human and mouse muscle. We recorded superresolution images of the NMJ using 3D-structured illumination microscopy. RESULTS We discovered a spontaneous missense mutation in CHD8 [chr14:g.21,884,051G>A, GRCh37.p11 | c.1732C>T, NM_00117062 | p.(R578C)], the gene encoding chromodomain helicase DNA-binding protein 8. This is the first missense mutation affecting Duplin, the short 110 kDa isoform of CHD8. It is known that CHD8/Duplin negatively regulates βCAT signalling in the WNT pathway and plays a role in chromatin remodelling. Inactivating CHD8 mutations are associated with autism spectrum disorder and intellectual disability in combination with facial dysmorphism, overgrowth and macrocephalus. No muscle-specific phenotype has been reported to date. Co-immunostaining with rapsyn on human and mouse muscle revealed a strong presence of CHD8 at the NMJ being located towards the sarcoplasmic side of the rapsyn cluster, where it co-localizes with βCAT. CONCLUSION We hypothesize CHD8 to have a role in the maintenance of the structural integrity and function of the NMJ. Both patients benefited from treatment with 3,4-diaminopyridine, a reversible blocker of voltage-gated potassium channels at the nerve terminal that prolongs the action potential and increases acetylcholine release.
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Affiliation(s)
- C Y Lee
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neuropediatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - M Petkova
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neuropediatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - S Morales-Gonzalez
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neuropediatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - N Gimber
- Advanced Medical Bioimaging Core Facility (AMBIO), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - J Schmoranzer
- Advanced Medical Bioimaging Core Facility (AMBIO), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - A Meisel
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - W Böhmerle
- Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - W Stenzel
- Department of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - M Schuelke
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neuropediatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - J M Schwarz
- NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neuropediatrics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Di Stefano V, Lupica A, Rispoli MG, Di Muzio A, Brighina F, Rodolico C. Rituximab in AChR subtype of myasthenia gravis: systematic review. J Neurol Neurosurg Psychiatry 2020; 91:392-395. [PMID: 32098874 DOI: 10.1136/jnnp-2019-322606] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 11/03/2022]
Abstract
Myasthenia gravis (MG) is a chronic autoimmune disorder of the neuromuscular junction characterised by an autoantibody against acetylcholine receptor (AChR-Ab), autoantibody against muscle-specific kinase (MuSK-Ab), lipoprotein-related protein 4 or agrin in the postsynaptic membrane at the neuromuscular junction. Many patients are resistant to conventional treatment and effective therapies are needed. Rituximab (RTX) is a monoclonal antibody directed against CD20 antigen on B cells which has been successfully employed in anti-MuSK-Ab+MG, but the efficacy in anti-AChR-Ab+MG is still debated. The purpose of this systematic review was to describe the best evidence for RTX in the acetylcholine receptor subtype. The authors undertook a literature search during the period of 1999-2019 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analys methodology, employing (myasthenia)+(gravis)+(RTX) as search terms. The analysis was confined to studies that include at least five patients with confirmed anti-AChR-Ab+MG. Thirteen studies have been selected, showing a good safety. The data obtained were heterogeneous in terms of posology, administration scheme and patients' evaluation, ranging from a minimum of two to a maximum of three cycles. RTX led to a sustained clinical improvement with prolonged time to relapse, in parallel to a reduction or discontinuation of other immunosuppressive therapies. Treatment with RTX appears to work in some but not all patients with anti-AChR-Ab+MG, but randomised controlled trials are needed. Future studies should take into account the subtype of MG and employ reliable measures of outcome and severity focusing on how to identify patients who may benefit from the treatment. Trial registration number: NCT02110706.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience and advanced Diagnostic, University of Palermo, Palermo, Sicily, Italy .,Department of Neuroscience Imaging and Clinical Sciences, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Abruzzo, Italy
| | - Antonino Lupica
- Department of Clinical and Experimental Medicine, Unit of Neurology and Neuromuscular Disease, University of Messina, Messina, Sicilia, Italy
| | - Marianna Gabriella Rispoli
- Department of Neuroscience Imaging and Clinical Sciences, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Abruzzo, Italy
| | - Antonio Di Muzio
- Department of Neurology, SS Annunziata Hospital, Chieti, Abruzzo, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience and advanced Diagnostic, University of Palermo, Palermo, Sicily, Italy
| | - Carmelo Rodolico
- Department of Clinical and Experimental Medicine, Unit of Neurology and Neuromuscular Disease, University of Messina, Messina, Sicilia, Italy
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Sachdeva J, Mahesh KV, Shree R, Jain G, Kapila AT, Shashikala TP, Goyal MK, Modi M, Lal V. Use of rituximab in muscle-specific tyrosine kinase antibody-positive myasthenia gravis: Preliminary observations from a tertiary care center in Northern India. Indian J Pharmacol 2020; 52:49-52. [PMID: 32201447 PMCID: PMC7074426 DOI: 10.4103/ijp.ijp_333_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/23/2019] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES: Approximately 10%–15% of patients with myasthenia gravis (MG) are refractory to standard treatment. A sizable chunk of these patients is due to muscle-specific tyrosine kinase (MuSK) antibody-positive MG which often runs a severe course with frequent relapses and poor response to conventional treatment. We report six patients with refractory MuSK-positive MG who responded well to the treatment with rituximab. PATIENTS AND METHODS: In this prospective institute-based observational study, we report six MuSK antibody-positive MG patients, who did not achieve remission with standard treatment and were later started on rituximab infusion. RESULTS: There was a significant clinical improvement in all patients after starting rituximab. CONCLUSION: Rituximab is an effective immunomodulatory therapy in MuSK antibody-positive MG patients who are not responding to the standard treatment.
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Affiliation(s)
- Julie Sachdeva
- Department of Neurology, Postgraduate Institute of Medical and Research, Chandigarh, India
| | - Karthik Vinay Mahesh
- Department of Neurology, Postgraduate Institute of Medical and Research, Chandigarh, India
| | - Ritu Shree
- Department of Neurology, Postgraduate Institute of Medical and Research, Chandigarh, India
| | - Gaurav Jain
- Department of Neurology, Postgraduate Institute of Medical and Research, Chandigarh, India
| | - Aastha Takkar Kapila
- Department of Neurology, Postgraduate Institute of Medical and Research, Chandigarh, India
| | | | - Manoj Kumar Goyal
- Department of Neurology, Postgraduate Institute of Medical and Research, Chandigarh, India
| | - Manish Modi
- Department of Neurology, Postgraduate Institute of Medical and Research, Chandigarh, India
| | - Vivek Lal
- Department of Neurology, Postgraduate Institute of Medical and Research, Chandigarh, India
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Fu KS, Wong PY, Hiew FL. Therapeutic plasma exchange (TPE) for semi-critical neurology presentations in a non-acute neurology set-up: clinical practice and challenges. BMJ Neurol Open 2020; 2:e000020. [PMID: 33681775 PMCID: PMC7871719 DOI: 10.1136/bmjno-2019-000020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/02/2020] [Accepted: 01/19/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction Therapeutic plasma exchange (TPE) for semi-critical neurological manifestations can be managed in non-acute setting instead of critical care unit. In 2014, we established a non-acute neurology TPE unit for semi-critical haemodynamically stable patients. In this study, we aimed to evaluate the technical and safety parameters from the first 3 years of service. Materials and methods We analysed prospectively collected TPE data for patients treated with centrifugation TPE at our non-acute neurology TPE unit in Kuala Lumpur Hospital between May 2015 and June 2018. Results A total of 245 TPE procedures were performed in 55 patients for nine neurological indications, predominantly the central nervous system (79%). Twenty four per cent (n=13) had category I and 73% (n=40) had category II indication (American Society for Apheresis (ASFA) 2019). Others (4%) were not in ASFA indications. Neuromyelitis optica spectrum disorders accounted for half (51%) of the total patients. Twenty-three (41.8%) patients experienced adverse events, with hypotensive episodes being the the most common (n=12/55, 21.8%). Five (9.1%) patients had catheter-related blood stream infection, correlating with higher exchange plasma volume (p=0.023). Symptomatic hypocalcaemia was less common (n=5/55, 9.1%) and allergic reaction to human albumin was rare (n=1/55, 1.8%). Four technical errors detected. Three involved centrifugation sets manufacturing defects and one involved error in centrifugation set installation. Seven (2.9%) procedures were terminated: 5 for adverse effects and 2 for technical errors. Conclusion Performing TPE among semi-critical patients with neurology manifestations in basic non-acute set-up proved safe, with predictable complications. This set-up reduced the reliance on critical care services for TPE procedures.
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Affiliation(s)
- Keng Seng Fu
- Department of Neurology, Hospital Kuala Lumpur, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Pei Yin Wong
- Department of Neurology, Hospital Kuala Lumpur, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Fu Liong Hiew
- Department of Neurology, Hospital Kuala Lumpur, Kuala Lumpur, Wilayah Persekutuan, Malaysia
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Abstract
Myasthenia gravis (MG) is a rare autoimmune disease mediated by pathogenic antibodies (Ab) directed against components of the neuromuscular junction (NMJ), mainly the acetylcholine receptor (AChR). The etiological mechanisms are not totally elucidated, but they include a combination of genetic predisposition, triggering event(s), and hormonal components. MG disease is associated with defective immune regulation, chronic cell activation, inflammation, and the thymus is frequently abnormal. MG is characterized by muscle fatigability that is very invalidating and can be life-threatening when respiratory muscles are affected. MG is not cured, and symptomatic treatments with acetylcholinesterase inhibitors and immunosuppressors are life-long medications associated with severe side effects (especially glucocorticoids). While the muscle is the ultimate target of the autoimmune attack, its place and role are not thoroughly described, and this mini-review will focus on the cascade of pathophysiologic mechanisms taking place at the NMJ and its consequences on the muscle biology, function, and regeneration in myasthenic patients, at the histological, cellular, and molecular levels. The fine structure of the synaptic cleft is damaged by the Ab binding that is coupled to focal complement-dependent lysis in the case of MG with anti-AChR antibodies. Cellular and molecular reactions taking place in the muscle involve several cell types as well as soluble factors. Finally, the regenerative capacities of the MG muscle tissue may be altered. Altogether, the studies reported in this review demonstrate that the muscle is not a passive target in MG, but interacts dynamically with its environment in several ways, activating mechanisms of compensation that limit the pathogenic mechanisms of the autoantibodies.
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Affiliation(s)
- Jean-Thomas Vilquin
- Sorbonne Université, INSERM, Association Institut de Myologie (AIM), Paris, France
| | | | - Rozen Le Panse
- Sorbonne Université, INSERM, Association Institut de Myologie (AIM), Paris, France
| | - Sonia Berrih-Aknin
- Sorbonne Université, INSERM, Association Institut de Myologie (AIM), Paris, France
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Abstract
BACKGROUND The neuromuscular disorders encountered in the pediatric intensive care unit (PICU) encompass a broad spectrum of pathologies. These include acute disorders (eg, Guillain-Barre syndrome), acute-on-chronic disorders (eg, myasthenia gravis), progressive disorders (eg, muscular dystrophy), and disorders that develop in the PICU (eg, critical illness myopathy/polyneuropathy). Familiarity with the presenting features of these disorders is of paramount importance in facilitating timely diagnosis. METHODS We conducted a retrospective review of the medical records of patients admitted to the PICU or Intermediate Care Program (ICP) at a single tertiary children's hospital from 2006 to 2017 with an acute or acute-on-chronic neuromuscular disorder. We did not include patients with a known progressive neuromuscular disorder or critical illness myopathy/polyneuropathy. RESULTS Twenty-four patients were admitted to the PICU/ICP with acute or acute-on-chronic neuromuscular disorders. Diagnosis and indication for ICU/ICP admission were Guillain-Barre syndrome (n = 6; respiratory failure: 3, respiratory monitoring: 2, autonomic instability: 1), myasthenia gravis (n = 5; airway clearance: 3, respiratory failure: 2), acute flaccid myelitis (n = 3; respiratory failure: 2, respiratory monitoring: 1), periodic paralysis (n = 3; intravenous potassium replacement), rhabdomyolysis (n = 3; monitoring for electrolyte derangements), infant botulism (n = 2; respiratory failure), chronic demyelinating polyneuropathy (n = 1; respiratory failure), and congenital myasthenic syndrome (n = 1; apnea). No patients were admitted to the PICU/ICP with a diagnosis of tick paralysis, acute intermittent porphyria, or inflammatory myopathy. CONCLUSIONS Although acute and acute-on-chronic neuromuscular disorders are encountered relatively rarely in the PICU, familiarity with the presenting features of these disorders is important in facilitating timely diagnosis. This, in turn, enables the institution of effective management strategies, thereby avoiding complications associated with diagnostic delays.
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Affiliation(s)
- Dana B Harrar
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Division of Neurology, Children's National Medical Center, Washington, DC, USA
| | - Basil T Darras
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Partha S Ghosh
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
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Streifel AM, Wessman LL, Schultz BJ, Miller D, Pearson DR. Refractory mucositis associated with underlying follicular dendritic cell sarcoma of the thymus: Paraneoplastic pemphigus versus malignancy-exacerbated pemphigus vulgaris. JAAD Case Rep 2019; 5:933-936. [PMID: 31687457 PMCID: PMC6820367 DOI: 10.1016/j.jdcr.2019.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | - Laurel L. Wessman
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota
| | | | - Daniel Miller
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota
| | - David R. Pearson
- Department of Dermatology, University of Minnesota, Minneapolis, Minnesota
- Correspondence to: David R. Pearson, MD, Department of Dermatology, University of Minnesota, 516 Delaware Street SE, Mail Code 98, Phillips-Wangensteen Bldg., Suite 4-240, Minneapolis, MN 55455.
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Cutter G, Xin H, Aban I, Burns TM, Allman PH, Farzaneh-Far R, Duda PW, Kaminski HJ. Cross-sectional analysis of the Myasthenia Gravis Patient Registry: Disability and treatment. Muscle Nerve 2019; 60:707-715. [PMID: 31487038 PMCID: PMC6899582 DOI: 10.1002/mus.26695] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 08/05/2019] [Accepted: 08/30/2019] [Indexed: 12/11/2022]
Abstract
Introduction The Myasthenia Gravis Patient Registry (MGR) is a voluntary, patient‐submitted database dedicated to improve understanding of care/burden of myasthenia gravis (MG). Methods In this study we present analyses of baseline records through July 2017 (n = 1140) containing data on the MG—Activities of Daily Living (MG‐ADL) and the MG 15‐item Quality of Life (MG‐QOL15) instruments, two validated scales assessing quality of life in MG patients at sign‐up into the MGR. Results Most registrants reported moderate to severe impairment of health‐related quality of life, with a median MG‐ADL score of 6 and a median MG‐QOL15 score of 21. Seventy‐one percent of the patients had received pyridostigmine. Corticosteroids, mycophenolate mofetil, and azathioprine were the most common immunomodulators/immunosuppressants, with 85% of participants having ever using one of these agents. Forty‐seven registrants reported receiving intravenous immunoglobulin, and 30% received plasma exchange. Twelve percent reported other treatments, and 40% were unsure whether they received less common therapies. Forty percent had undergone thymectomy. Discussion The MGR data correlate well with other MG cohorts. Many MG patients remain negatively impacted despite treatment.
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Affiliation(s)
- Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Haichang Xin
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Inmaculada Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ted M Burns
- Department of Neurology, University of Virginia, Charlottesville, Virginia
| | - Phillip H Allman
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ramin Farzaneh-Far
- Department of Clinical Research, Ra Pharmaceuticals, Inc., Cambridge, Massachusetts
| | - Petra W Duda
- Department of Clinical Research, Ra Pharmaceuticals, Inc., Cambridge, Massachusetts
| | - Henry J Kaminski
- Department of Neurology, George Washington University, Washington, DC
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Cetin H, Epstein M, Liu WW, Maxwell S, Rodriguez Cruz PM, Cossins J, Vincent A, Webster R, Biggin PC, Beeson D. Muscle acetylcholine receptor conversion into chloride conductance at positive potentials by a single mutation. Proc Natl Acad Sci U S A 2019; 116:21228-35. [PMID: 31570625 DOI: 10.1073/pnas.1908284116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
We report on a single mutation in the α1-subunit M2 helix (p.α1Leu251Arg) of the muscle acetylcholine receptor (AChR) found in a patient with congenital myasthenic syndrome (CMS) that is shown to convert the AChR into chloride conductance at positive potentials. Constriction of the channel pore with partial desolvation and stabilization of the permeating chloride ions by the arginine residues is revealed as the underlying mechanism. This article is of general interest because it describes a mechanism for the transformation of the muscle AChR into an inhibitory channel, and presents a report of charge selectivity conversion in association with a naturally occurring single mutation. Our findings might also give explanation to a pathomechanism in CMS. Charge selectivity forms the basis of cellular excitation or inhibition by Cys-loop ligand-gated ion channels (LGICs), and is essential for physiological receptor function. There are no reports of naturally occurring mutations in LGICs associated with the conversion of charge selectivity. Here, we report on a CHRNA1 mutation (α1Leu251Arg) in a patient with congenital myasthenic syndrome associated with transformation of the muscle acetylcholine receptor (AChR) into an inhibitory channel. Performing patch-clamp experiments, the AChR was found to be converted into chloride conductance at positive potentials, whereas whole-cell currents at negative potentials, although markedly reduced, were still carried by sodium. Umbrella sampling molecular dynamics simulations revealed constriction of the channel pore radius to 2.4 Å as a result of the mutation, which required partial desolvation of the ions in order to permeate the pore. Ion desolvation was associated with an energetic penalty that was compensated for by the favorable electrostatic interaction of the positively charged arginines with chloride. These findings reveal a mechanism for the transformation of the muscle AChR into an inhibitory channel in a clinical context.
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Abstract
Neurologists are very familiar with using corticosteroids and are aware of their considerable risk of adverse effects with prolonged use. Thus, we frequently consider alternative immunosuppression or corticosteroid sparing agents. However, unlike other specialties, such as rheumatology, there are few indications for corticosteroid-sparing agents in neurology and so our experience is less extensive; even these indications may reduce further as more disease-modifying treatments become available for neurological conditions. Azathioprine is perhaps the most commonly used corticosteroid-sparing agent in neurology. This review aims to remind neurologists of important aspects of azathioprine prescribing, focussing on enhancing patient safety and clinician confidence in its prescribing.
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Affiliation(s)
| | - Usman Khan
- Neurology, St George's University Hospital, London, UK
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47
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Nishida Y, Takahashi YK, Kanai T, Nose Y, Ishibashi S, Sanjo N, Uzawa A, Oda F, Ozawa Y, Kuwabara S, Noguchi E, Suzuki S, Nakahara J, Suzuki N, Ogawa T, Yokoyama K, Hattori N, Konno S, Fujioka T, Kawaguchi N, Hatanaka Y, Sonoo M, Kaneko J, Ogino M, Nishiyama K, Nomura K, Yokota T. Safety of tapering tacrolimus dose in patients with well-controlled anti-acetylcholine receptor antibody-positive myasthenia gravis. Eur J Neurol 2019; 27:100-104. [PMID: 31309642 DOI: 10.1111/ene.14039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/10/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE Tapering immunosuppressants is desirable in patients with well-controlled myasthenia gravis (MG). However, the association between tapering of calcineurin inhibitor dosage and reduction-associated exacerbation is not known. The aim of this study was to clarify the frequency of reduction-associated exacerbation when tacrolimus is tapered in stable patients with anti-acetylcholine receptor antibody-positive MG, and to determine the factors that predict exacerbations. METHODS We retrospectively analyzed 115 patients in whom tacrolimus dosage was tapered. The reduction-associated exacerbation was defined as the appearance or worsening of one or more MG symptoms <3 months after the reduction. RESULTS Tacrolimus dosage was successfully tapered in 110 patients (96%) without any exacerbation. Five patients (4%) experienced an exacerbation, but symptoms were reversed in all patients when the tacrolimus dose was increased to the previous maintenance level. No patient developed an MG crisis. The age at onset was significantly earlier (30 vs. 56 years, P = 0.025) and the reduction in dosage was significantly larger (2.0 vs. 1.0 mg/day, P = 0.002) in patients with reduction-associated exacerbation than in those without exacerbation. The cut-off values determined in a receiver-operating characteristic curve analysis were 52 years (sensitivity, 57%; specificity, 100%) for the age at onset and 1.5 mg (sensitivity, 80%; specificity, 100%) for the dose reduction. CONCLUSION Tapering of tacrolimus was possible in most patients with well-controlled anti-acetylcholine receptor antibody-positive MG. Early age at onset and a large reduction from maintenance dosage were associated with exacerbation. Reductions ≤1.5 mg/day from the maintenance dosage should be considered for patients with late-onset disease.
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Affiliation(s)
- Y Nishida
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Y K Takahashi
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - T Kanai
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Y Nose
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - S Ishibashi
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - N Sanjo
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - A Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - F Oda
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Y Ozawa
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - S Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - E Noguchi
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - S Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - J Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - N Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - T Ogawa
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - K Yokoyama
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - N Hattori
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - S Konno
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - T Fujioka
- Department of Neurology, Toho University Ohashi Medical Center, Tokyo, Japan
| | | | - Y Hatanaka
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
| | - M Sonoo
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
| | - J Kaneko
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - M Ogino
- School of Medicine, Center for Medical Education, International University of Health and Welfare, Chiba, Japan
| | - K Nishiyama
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - K Nomura
- Department of Neurology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - T Yokota
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Gamez J, Salvadó M, Carmona F, de Nadal M, Romero L, Ruiz D, Jáuregui A, Martínez O, Pérez J, Suñé P, Deu M. Intravenous immunoglobulin to prevent myasthenic crisis after thymectomy and other procedures can be omitted in patients with well-controlled myasthenia gravis. Ther Adv Neurol Disord 2019; 12:1756286419864497. [PMID: 31360225 PMCID: PMC6640060 DOI: 10.1177/1756286419864497] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Myasthenic crisis (MC) is a potentially life-threatening complication of myasthenia gravis. Its precipitating factors include surgical procedures, particularly thymectomy. The role of preoperative intravenous immunoglobulin (IVIg) in preventing MC in patients scheduled for thymectomy and other surgery with general anaesthesia is unknown. Our objective was to test the hypothesis that preoperative IVIg is effective in preventing myasthenic crisis in patients with myasthenia gravis scheduled for surgery under general anaesthesia, including thymectomy. Methods: A prospective, randomized, double-blind, single-centre study was conducted over a 4-year period. The treatment group received IVIg, 0.4 g/kg/day preoperatively for 5 consecutive days, and the placebo group received saline solution under the same conditions. The two groups were age-matched, with similar functional status, and Myasthenia Gravis Foundation of America class. All patients had well-controlled myasthenia gravis with minimal manifestations before surgery. The primary outcome measured was MC. Intubation times, time in the recovery room, number of postoperative complications, and days of hospitalization were the secondary outcomes measured. Results: A total of 47 patients were randomized, 25 to the IVIg group and 22 to placebo. There were 19 men and 28 women, with a mean age of 58.6 years, mean body mass index of 27.8 kg/m2, and mean acetylcholine receptor antibodies of 12.9 nmol/l. The mean forced vital capacity was 84.4%. The mean quantitative myasthenia gravis sum score was 6.3. Ten patients (five in each arm) had a history of MC. Thymectomy was performed in 16 patients. Only one patient in the placebo group presented with MC requiring non-invasive ventilation (but no reintubation) for 6 days. Neither differences between groups in the univariate analysis nor risk factors for MC in the multivariate analysis were found. Conclusions: Preoperative IVIg to prevent MC does not appear to be justified in well-controlled myasthenia gravis patients. This study provides class I evidence that preparation with IVIg to prevent MC is not necessary in well-controlled myasthenia gravis patients scheduled for surgery with general anaesthesia.
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Affiliation(s)
- Josep Gamez
- Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute (VHRI), European Reference Network on Rare Neuromuscular Diseases (ERN EURO-NMD), Department of Medicine, Universitat Autònoma de Barcelona. Passeig de la Vall d'Hebron 119-129, Barcelona E-08035, Spain
| | - María Salvadó
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Francesc Carmona
- Department of Genetics, Microbiology and Statistics, University of Barcelona, Barcelona, Spain
| | - Miriam de Nadal
- Department of Anesthesiology and Intensive Care, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Romero
- Department of Thoracic Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniel Ruiz
- Department of Anesthesiology and Intensive Care, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alberto Jáuregui
- Department of Thoracic Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Olga Martínez
- Department of Anesthesiology and Intensive Care, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Javier Pérez
- Department of Thoracic Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Pilar Suñé
- Department of Hospital Pharmacy, Vall d'Hebron University Hospital, Barcelona, Spain
| | - María Deu
- Department of Thoracic Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
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Abstract
The management of myasthenia gravis (MG) during pregnancy requires special skills as both diseases as well as its treatment can have deleterious effects on mother and fetus. MG often affects women in second and third decades of life during the childbearing age. Exacerbations of MG are likely to occur during the first trimester and postpartum period. The treatment of MG during pregnancy needs to be individualized depending on the severity of MG as well as the efficacy of various treatment modalities and their possible harmful effects on pregnancy. In addition, special attention has to be given to avoid drugs and other factors (such as urinary tract infections) which may worsen MG. The key to successful outcome during pregnancy in myasthenic women lies in multidisciplinary care involving obstetricians, neurologists, anesthetist as well as neonatologist. In this review, we discuss various therapeutic options available for the management of MG during pregnancy and provide recommendations based on the current best evidence.
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Affiliation(s)
| | - Manoj Kumar Goyal
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Modi
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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50
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Abstract
Objectives Patients with muscle-specific kinase (MuSK)-positive myasthenia are generally considered to have a grave prognosis. We present our experience of patients with myasthenia with different antibody status. This is followed by a short discourse on previous studies and the current view on MuSK-positive myasthenia, focusing on the associated prejudice. Materials and Methods This study compares 23 patients with MuSK-positive myasthenia with 55 patients with acetylcholine receptor-positive myasthenia and 9 patients with double-seronegative myasthenia at a tertiary level center. Results We did not find any significant difference in terms of clinical characteristics, treatment response to immunosuppressants, long-term prognosis, and quality of life. Conclusion Seropositivity for antibodies should not be used in isolation to guide the management or predict the prognosis. Undue negative prognostication may affect the morale of patient. Clinical features and response to therapy in addition to antibody status must be considered before planning therapy.
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Affiliation(s)
- Priyanka Samal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Vinay Goyal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta B Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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