A Case of Probable Multifocal Motor Neuropathy With Clinical Stability for Ten Years After a Single Treatment of Rituximab

ABSTRACT

Multifocal motor neuropathy is a rare, immune-mediated motor neuropathy with asymmetric, often debilitating progressive weakness. The efficacy of intravenous immunoglobulin in this disease is well established; however, the response typically wanes over time. No other agent has shown similar therapeutic efficacy. We describe a case of anti-ganglioside GM1 IgM-positive multifocal motor neuropathy with typical incomplete and diminishing response to intravenous immunoglobulin over time. Sixteen years after symptom onset, rituximab was administered at 2 g/m2 over 2 weeks. No significant progression of disease has occurred over the following 10 years despite no additional treatments, including intravenous immunoglobulin, being given. Only case reports and small, mostly uncontrolled studies have reported the use of rituximab in multifocal motor neuropathy with mixed results. However, given its potential benefits and lack of an established second-line agent, treatment with rituximab may be considered in select patients with refractory multifocal motor neuropathy.

The Role of Imaging for Disorders of Peripheral Nerve

Peripheral nerve imaging is a helpful and sometimes essential adjunct to clinical history, physical examination, and electrodiagnostic studies. Advances in imaging technology have allowed the visualization of nerve structures and their surrounding tissues. The clinical applications of ultrasound and magnetic resonance imaging (MRI) in the evaluation of peripheral nerve disorders are growing exponentially. This article reviews basics of ultrasound and MRI as they relate to nerve imaging, reviews advantages and limitations of each imaging modality, reviews the applications of ultrasound and MRI in disorders of peripheral nerve, and discusses emerging advances in the field.

Knowledge and perceptions of the COVID-19 pandemic among patients with myasthenia gravis

BACKGROUND

Patients with myasthenia gravis (MG) may be particularly vulnerable during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic due to risk of worsening disease during infection, potential adverse impacts of coronavirus disease 2019 (COVID-19) treatments on neuromuscular transmission, and a limited ability to fight off infection related to immunosuppressive treatments. Our goal is to understand how patients are experiencing the COVID-19 pandemic, including where they receive relevant information, how it has affected medical care, and what measures they use to protect themselves.

METHODS

This is a prospective online survey study at large academic practice. All patients with a neuromuscular junction disorder diagnosis code in the Duke Health System were invited to participate.

RESULTS

One thousand eight hundred and forty eight patients were approached to participate and 75 completed the survey between 16 April 2020 and 28 May 2020. The most frequently used information sources were non-presidential federal government (75%), state government (57%), local healthcare provider (37%), and television news (36%). Non-presidential federal government (80%), local healthcare providers (55%), state government (33%), and patient support organizations (29%) were considered the most trusted information sources. Thirty-three (44%) of survey responders had attended a telemedicine visit. Patients were taking recommended precautions during the pandemic and remained very concerned (69%) about COVID-19. Generalized Anxiety Disorder-7 scores were moderate-severe in 20% of responders.

CONCLUSIONS

Healthcare providers, the government, and patient organizations play a critical role in communicating with the MG patient community. Use of targeted messaging strategies by these groups to convey accurate information may increase effectiveness and lead to more informed patients with reduced anxiety.

Neuromuscular ultrasound in clinical practice: A review

Neuromuscular ultrasound (NMUS) is becoming a standard element in the evaluation of peripheral nerve and muscle disease. When obtained simultaneously to electrodiagnostic studies, it provides dynamic, structural information that can refine a diagnosis or identify a structural etiology. NMUS can improve patient care for those with mononeuropathies, polyneuropathy, motor neuron disease and muscle disorders. In this article, we present a practical guide to the basics of NMUS and its clinical application. Basic ultrasound physics, scanning techniques and clinical applications are reviewed, along with current challenges.

Myasthenia triggered by immune checkpoint inhibitors: New case and literature review

Immune checkpoint molecules are potent regulators of immunologic homeostasis that prevent the development of autoimmunity while maintaining self-tolerance. Inhibitors of immune checkpoint molecules are used as immunotherapy in the treatment of melanoma and different types of refractory cancer, and can trigger various autoimmune complications including myositis and myasthenia gravis. We describe a case of generalized myasthenia gravis induced by pembrolizumab and review 11 other cases. Five patients also had elevated serum CK levels ranging from 1200 to 8729 IU/L, and biopsy showed myositis in one. Severity was highly variable as symptoms normalized spontaneously in one patient, but three others developed myasthenic crisis (including two with fatal outcomes). Steroids have been recommended as a preferred treatment of autoimmune complications of immune-checkpoint inhibitors. Myasthenia gravis should be considered when weakness, diplopia or bulbar symptoms are seen after treatment with immune checkpoint inhibitors, and additional studies are needed to characterize association with hyperCKemia.

[Uterine activity in primiparous and multiparous women in spontaneous labor and induced labor with oxytocin]

An analysis was performed of 5187 intra-amniotically measured labor pressure curves in 40 births with spontaneous labour (20 primiparae and 20 multiparae) and 40 births births in which labor was induced with oxytocin (20 primiparae and 20 multiparae). The dilatation of the os uteri was divided into three phases--Phase 1, dilatation of the cervix to 2 cm; Phase 2, dilatation of the cervix from 2 to 4 cm, and Phase 3, dilatation from 4 cm onwards until complete. During the active phase, from 2 cm until dilatation of the os uteri was complete, no differences were observed between induced and spontaneous labor with regard to frequency and amplitude of contractions. In the induced-labor cases, the parameters for uterine activity, maximum contraction and dilatation speed were higher in all three phases of labor, and those for total duration of labor lower than in the spontaneous labor cases. The contraction/dilatation speed is an important parameter for monitoring the effect of drug-induced stimulation of labor. In the latency phase in spontaneous labor, more contractions were observed in multiparae than in primiparae. This fact which should be reason enough to intensify monitoring of both mother and fetus during this phase. In light of these results it would appear advisable, in the absence of progress in labor, to make a clear distinction between the goals of cervical maturity and promotion of uterine activity, and to institute different drug therapy accordingly.

The Organization of Work in China's Communes

There has been speculation that China's communes are undergoing drastic changes and that work patterns are being redefined so as to make individuals or households the basic production units in agriculture. A brief but intensive anthropological study in 17 communes suggests that, although collectivization is still considered to be the ideal form in more advanced areas, responsibility for some tasks is being assigned to households in some poorer communes in an effort to increase production and farm incomes and enhance development. Significant permanent improvements seem hinged to the rise of rural industry, which increasingly rewards individual efforts within the context of a basically collective social organization. The system is complex and is more flexible than it has been in the recent past.