1
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Scorr LM, Kilic-Berkmen G, Sutcliffe DJ, Dinasarapu AR, McKay JL, Bagchi P, Powell MD, Boss JM, Cereb N, Little M, Gragert L, Hanfelt J, McKeon A, Tyor W, Jinnah HA. Exploration of potential immune mechanisms in cervical dystonia. Parkinsonism Relat Disord 2024; 122:106036. [PMID: 38462403 PMCID: PMC11162750 DOI: 10.1016/j.parkreldis.2024.106036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/01/2024] [Accepted: 02/09/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Although there are many possible causes for cervical dystonia (CD), a specific etiology cannot be identified in most cases. Prior studies have suggested a relationship between autoimmune disease and some cases of CD, pointing to possible immunological mechanisms. OBJECTIVE The goal was to explore the potential role of multiple different immunological mechanisms in CD. METHODS First, a broad screening test compared neuronal antibodies in controls and CD. Second, unbiased blood plasma proteomics provided a broad screen for potential biologic differences between controls and CD. Third, a multiplex immunoassay compared 37 markers associated with immunological processes in controls and CD. Fourth, relative immune cell frequencies were investigated in blood samples of controls and CD. Finally, sequencing studies investigated the association of HLA DQB1 and DRB1 alleles in controls versus CD. RESULTS Screens for anti-neuronal antibodies did not reveal any obvious abnormalities. Plasma proteomics pointed towards certain abnormalities of immune mechanisms, and the multiplex assay pointed more specifically towards abnormalities in T lymphocytes. Abnormal immune cell frequencies were identified for some CD cases, and these cases clustered together as a potential subgroup. Studies of HLA alleles indicated a possible association between CD and DRB1*15:03, which is reported to mediate the penetrance of autoimmune disorders. CONCLUSIONS Altogether, the association of CD with multiple different blood-based immune measures point to abnormalities in cell-mediated immunity that may play a pathogenic role for a subgroup of individuals with CD.
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Affiliation(s)
- Laura M Scorr
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Gamze Kilic-Berkmen
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Diane J Sutcliffe
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Ashok R Dinasarapu
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - J Lucas McKay
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA; Department of Biomedical Infortmatics, Emory School of Medicine, Atlanta, GA, 30322, USA
| | - Pritha Bagchi
- Integrated Proteomics Core, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Michael D Powell
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Jeremy M Boss
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | | | - Marian Little
- Division of Biomedical Informatics and Genomics, Department of Medicine, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Loren Gragert
- Division of Biomedical Informatics and Genomics, Department of Medicine, Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - John Hanfelt
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, GA, 30322, USA
| | - Andrew McKeon
- Department of Laboratory Medicine and Pathology, Neurology and Immunology and Department of Neurology, Mayo Clinic, Rochester Mayo Clinic, Rochester, 55902, MN, USA
| | - William Tyor
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA; Atlanta VA Medical Center, Decatur, GA, 30033, USA
| | - H A Jinnah
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA; Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, 30322, USA.
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Kilic-Berkmen G, Scorr LM, Rosen A, Wu E, Freeman A, Silver M, Hanfelt J, Jinnah HA. Thyroid disease in cervical dystonia. Parkinsonism Relat Disord 2023; 107:105274. [PMID: 36621155 PMCID: PMC10257803 DOI: 10.1016/j.parkreldis.2022.105274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/04/2022] [Accepted: 12/29/2022] [Indexed: 01/01/2023]
Abstract
There are many possible etiologies for cervical dystonia (CD), but a cause cannot be identified in most cases. Most recent attention has focused on genetic causes, although a few prior studies have highlighted autoimmune mechanisms instead. Because autoimmune disorders frequently co-exist, the current study evaluated the hypothesis that autoimmune disorders might be more common in CD than neurological controls. The frequency of 32 common autoimmune disorders was evaluated using a systematic survey comparing 300 subjects with CD with 391 neurological controls. The frequency of thyroid disease was significantly higher in CD (20%) compared with controls (6%). Regression analyses that accounted for age and sex revealed an odds ratio of 4.5 (95% CI 2.5-8.1, p < 0.001). All other autoimmune disorders occurred with similar frequencies in CD and controls. Although these studies do not establish a mechanistic link between CD and autoimmune disease, they suggest the need for further attention to a potential relationship, and more specifically with thyroid disease.
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Affiliation(s)
- Gamze Kilic-Berkmen
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Laura M Scorr
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Ami Rosen
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Ellen Wu
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Alan Freeman
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Michael Silver
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - John Hanfelt
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, GA, 30322, USA
| | - H A Jinnah
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, 30322, USA; Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, 30322, USA.
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3
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Is myasthenia gravis a contraindication for botulinum toxin? J Clin Neurosci 2021; 95:44-47. [PMID: 34929650 DOI: 10.1016/j.jocn.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/06/2021] [Accepted: 11/11/2021] [Indexed: 11/20/2022]
Abstract
Botulinum toxin (BTX) is a neurotoxin that has been used to treat various disorders and has also become a popular choice for cosmetic indications, yet traditionally, myasthenia gravis (MG) is considered a contraindication for BTX. To determine whether BTX should be avoided in MG patients, clinical data from our MG and dystonia specialist clinic were analyzed retrospectively. In addition, a systematic literature review was conducted to identify all published cases associated with the co-existence of MG and BTX treatments. Here, we described one patient from our clinic, who received BTX injections before being given MG diagnosis. After the literature review, 8 cases with subclinical MG previously treated with BTX for dystonia or cosmetic reasons ("BTX injections before MG diagnosis") were identified. Markedly, 8 out of 8 (100%) patients developed obvious muscle weakness. In contrast, 10 patients presenting MG as comorbidity had received BTX for dystonia or overactive bladder ("BTX injection after MG diagnosis"), and 8 out of 10 (80%) experienced improved symptoms through appropriate dose modifications and adequate treatment for MG before receiving BTX injections. These findings support that, under proper management of co-existing MG, BTX could be used safely and successfully in patients presenting MG comorbidities in the future.
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4
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Moron H, Gagnard-Landra C, Guiraud D, Dupeyron A. Contribution of Single-Fiber Evaluation on Monitoring Outcomes Following Injection of Botulinum Toxin-A: A Narrative Review of the Literature. Toxins (Basel) 2021; 13:toxins13050356. [PMID: 34067540 PMCID: PMC8156529 DOI: 10.3390/toxins13050356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 11/24/2022] Open
Abstract
Botulinum toxin-A (BoNT-A) blocks acetylcholine release at the neuromuscular junction (NMJ) and is widely used for neuromuscular disorders (involuntary spasms, dystonic disorders and spasticity). However, its therapeutic effects are usually measured by clinical scales of questionable validity. Single-fiber electromyography (SFEMG) is a sensitive, validated diagnostic technique for NMJ impairment such as myasthenia. The jitter parameter (µs) represents the variability of interpotential intervals of two muscle fibers from the same motor unit. This narrative review reports SFEMG use in BoNT-A treatment. Twenty-four articles were selected from 175 eligible articles searched in Medline/Pubmed and Cochrane Library from their creation until May 2020. The results showed that jitter is sensitive to early NMJ modifications following BoNT-A injection, with an increase in the early days’ post-injection and a peak between Day 15 and 30, when symptoms diminish or disappear. The reappearance of symptoms accompanies a tendency for a decrease in jitter, but always precedes its normalization, either delayed or nonexistent. Increased jitter is observed in distant muscles from the injection site. No dose effect relationship was demonstrated. SFEMG could help physicians in their therapeutic evaluation according to the pathology considered. More data are needed to consider jitter as a predictor of BoNT-A clinical efficacy.
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Affiliation(s)
- Hélène Moron
- Department of Functional Exploration of the Nervous System and Acupuncture, CHU Nîmes, Univ Montpellier, 30029 Nîmes, France;
- EuroMov DHM, IMT Ales, Univ Montpellier, 34090 Montpellier, France;
- CAMIN, INRIA, Univ Montpellier, 34090 Montpellier, France;
- Correspondence:
| | - Corine Gagnard-Landra
- Department of Functional Exploration of the Nervous System and Acupuncture, CHU Nîmes, Univ Montpellier, 30029 Nîmes, France;
| | - David Guiraud
- CAMIN, INRIA, Univ Montpellier, 34090 Montpellier, France;
| | - Arnaud Dupeyron
- EuroMov DHM, IMT Ales, Univ Montpellier, 34090 Montpellier, France;
- Department of Physical and Rehabilitation Medicine, CHU Nîmes, Univ Montpellier, 30029 Nîmes, France
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5
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Sheikh S, Alvi U, Soliven B, Rezania K. Drugs That Induce or Cause Deterioration of Myasthenia Gravis: An Update. J Clin Med 2021; 10:jcm10071537. [PMID: 33917535 PMCID: PMC8038781 DOI: 10.3390/jcm10071537] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 12/20/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neuromuscular disorder which is characterized by presence of antibodies against acetylcholine receptors (AChRs) or other proteins of the postsynaptic membrane resulting in damage to postsynaptic membrane, decreased number of AChRs or blocking of the receptors by autoantibodies. A number of drugs such as immune checkpoint inhibitors, penicillamine, tyrosine kinase inhibitors and interferons may induce de novo MG by altering the immune homeostasis mechanisms which prevent emergence of autoimmune diseases such as MG. Other drugs, especially certain antibiotics, antiarrhythmics, anesthetics and neuromuscular blockers, have deleterious effects on neuromuscular transmission, resulting in increased weakness in MG or MG-like symptoms in patients who do not have MG, with the latter usually being under medical circumstances such as kidney failure. This review summarizes the drugs which can cause de novo MG, MG exacerbation or MG-like symptoms in nonmyasthenic patients.
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6
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Dressler D, Altavista MC, Altenmueller E, Bhidayasiri R, Bohlega S, Chana P, Chung TM, Colosimo C, Fheodoroff K, Garcia-Ruiz PJ, Jeon B, Jin L, Kanovsky P, Milanov I, Micheli F, Orlova O, Pandey S, Pirtosek Z, Relja M, Rosales R, Sagástegui-Rodríguez JA, Shahidi GA, Timerbaeva S, Wan X, Walter U, Saberi FA. Consensus guidelines for botulinum toxin therapy: general algorithms and dosing tables for dystonia and spasticity. J Neural Transm (Vienna) 2021; 128:321-335. [PMID: 33635442 PMCID: PMC7969540 DOI: 10.1007/s00702-021-02312-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 01/22/2021] [Indexed: 12/01/2022]
Abstract
Botulinum toxin (BT) therapy is a complex and highly individualised therapy defined by treatment algorithms and injection schemes describing its target muscles and their dosing. Various consensus guidelines have tried to standardise and to improve BT therapy. We wanted to update and improve consensus guidelines by: (1) Acknowledging recent advances of treatment algorithms. (2) Basing dosing tables on statistical analyses of real-life treatment data of 1831 BT injections in 36 different target muscles in 420 dystonia patients and 1593 BT injections in 31 different target muscles in 240 spasticity patients. (3) Providing more detailed dosing data including typical doses, dose variabilities, and dosing limits. (4) Including total doses and target muscle selections for typical clinical entities thus adapting dosing to different aetiologies and pathophysiologies. (5) In addition, providing a brief and concise review of the clinical entity treated together with general principles of its BT therapy. For this, we collaborated with IAB—Interdisciplinary Working Group for Movement Disorders which invited an international panel of experts for the support.
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Affiliation(s)
- Dirk Dressler
- Movement Disorders Section, Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | | | - Eckart Altenmueller
- Institute of Music Physiology and Musicians' Medicine, Hanover University of Music, Drama and Media, Hannover, Germany
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre for Excellence on Parkinson's Disease and Related Disorders, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Saeed Bohlega
- Department of Neurology, King Faisal Specialist Hospital, Riyyad, Kingdom of Saudi Arabia
| | - Pedro Chana
- Department of Neurology, University de Santiago de Chile, Santiago de Chile, Chile
| | | | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, Terni, Italy
| | | | | | - Beomseok Jeon
- Department of Neurology, Seoul National University, Seoul, Republic of Korea
| | - Lingjing Jin
- Department of Neurology, Tongji University School of Medicine, Shanghai, China
| | - Petr Kanovsky
- Department of Neurology, Palacky University, Olomouc, Czech Republic
| | - Ivan Milanov
- Department of Neurology, Medical University of Sofia, Sofia, Bulgaria
| | - Federico Micheli
- Department of Neurology, Hospital de Clínicas José de San Martín, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Sanjay Pandey
- Department of Neurology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Zvezdan Pirtosek
- Department of Neurology, Ljubljana University, Ljubljana, Slovenia
| | - Maja Relja
- Department of Neurology, University of Zagreb, Zagreb, Croatia
| | - Raymond Rosales
- Department of Neurology, University of Santo Tomas, Manila, Philippines
| | | | - Gholam Ali Shahidi
- Department of Neurology, Iran University of Medical Sciences, Tehran, Iran
| | | | - Xinhua Wan
- Department of Neurology, Peking Union Medical College, Beijing, China
| | - Uwe Walter
- Department of Neurology, Rostock University, Rostock, Germany
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7
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Elavarasi A, Goyal V. Botulinum neurotoxin in the treatment of hemifacial spasm associated with myasthenia gravis. Toxicon 2020; 190:1-2. [PMID: 33253699 DOI: 10.1016/j.toxicon.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/29/2020] [Accepted: 11/19/2020] [Indexed: 11/27/2022]
Affiliation(s)
| | - Vinay Goyal
- Institute of Neurosciences, Medanta The Medicity, NCR, India.
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8
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Timmermans G, Depierreux F, Wang F, Hansen I, Maquet P. Cosmetic Injection of Botulinum Toxin Unmasking Subclinical Myasthenia Gravis: A Case Report and Literature Review. Case Rep Neurol 2019; 11:244-251. [PMID: 31572161 PMCID: PMC6751432 DOI: 10.1159/000502350] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 07/26/2019] [Indexed: 11/19/2022] Open
Abstract
Cosmetic or therapeutic use of botulinum toxin type A (BoNT-A) is usually safe but can rarely cause iatrogenic botulism. Iatrogenic botulism and myasthenia gravis (MG) share similar clinical features, because both BoNT-A and anti-acetylcholine receptorantibodies impair neuromuscular transmission. We report a patient who underwent cosmetic BoNT-A injection and later developed serious local and systemic adverse reactions. The peculiarity of this case is that a latent seropositive MG was eventually discovered, suggesting that both iatrogenic botulism and MG contributed to the clinical picture. This patient is one of the less than 10 reported cases worldwide in whom MG was unmasked by BoNT-A injection. He is the first to be assessed in detail by single-fiber electromyography. This case emphasizes the risk associated with BoNT-A injection in patients with subclinical impairment of neuromuscular transmission and prompts the search for MG in case of exaggerated response.
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Affiliation(s)
- Grégory Timmermans
- Department of Neurology, University of Liège, CHU Sart-Tilman, Liège, Belgium
| | | | - François Wang
- Department of Neurophysiology, University of Liège, CHU Sart-Tilman, Liège, Belgium
| | - Isabelle Hansen
- Department of Neurology, University of Liège, CHU Sart-Tilman, Liège, Belgium
| | - Pierre Maquet
- Department of Neurology, University of Liège, CHU Sart-Tilman, Liège, Belgium
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Watts J, Brew B, Tisch S. Myasthenia gravis exacerbation with low dose ocular botulinum toxin for epiphoria. J Clin Neurosci 2015; 22:1979-81. [PMID: 26188667 DOI: 10.1016/j.jocn.2015.05.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 05/30/2015] [Indexed: 10/23/2022]
Abstract
We present a man with clinically stable systemic myasthenia gravis (MG) which flared with a low dose of peripherally injected botulinum toxin type A (BTX-A). Botulinum toxin drugs generally have an excellent safety profile, however, they are contentious in patients with neuromuscular disorders. Despite this, there remain limited reports on the systemic effects of botulinum therapy in patients with MG. This man is one of less than 10 reported patients worldwide in whom MG was exacerbated by a peripheral BTX-A injection. This is an important reminder to Australian clinicians of the potential risks of this common place medication in patients with neuromuscular disorders, even those with stable disease.
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Affiliation(s)
- Jennifer Watts
- St Vincents Hospital, Victoria Street, Darlinghurst, NSW 2010, Australia.
| | - Bruce Brew
- St Vincents Hospital, Victoria Street, Darlinghurst, NSW 2010, Australia; University of New South Wales, Kingsford, NSW, Australia
| | - Stephen Tisch
- St Vincents Hospital, Victoria Street, Darlinghurst, NSW 2010, Australia; University of New South Wales, Kingsford, NSW, Australia
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10
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Wheeler A, Smith HS. Botulinum toxins: mechanisms of action, antinociception and clinical applications. Toxicology 2013; 306:124-46. [PMID: 23435179 DOI: 10.1016/j.tox.2013.02.006] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 02/07/2013] [Accepted: 02/10/2013] [Indexed: 10/27/2022]
Abstract
Botulinum toxin (BoNT) is a potent neurotoxin that is produced by the gram-positive, spore-forming, anaerobic bacterium, Clostridum botulinum. There are 7 known immunologically distinct serotypes of BoNT: types A, B, C1, D, E, F, and G. Clostridum neurotoxins are produced as a single inactive polypeptide chain of 150kDa, which is cleaved by tissue proteinases into an active di-chain molecule: a heavy chain (H) of ∼100 kDa and a light chain (L) of ∼50 kDa held together by a single disulfide bond. Each serotype demonstrates its own varied mechanisms of action and duration of effect. The heavy chain of each BoNT serotype binds to its specific neuronal ecto-acceptor, whereby, membrane translocation and endocytosis by intracellular synaptic vesicles occurs. The light chain acts to cleave SNAP-25, which inhibits synaptic exocytosis, and therefore, disables neural transmission. The action of BoNT to block the release of acetylcholine botulinum toxin at the neuromuscular junction is best understood, however, most experts acknowledge that this effect alone appears inadequate to explain the entirety of the neurotoxin's apparent analgesic activity. Consequently, scientific and clinical evidence has emerged that suggests multiple antinociceptive mechanisms for botulinum toxins in a variety of painful disorders, including: chronic musculoskeletal, neurological, pelvic, perineal, osteoarticular, and some headache conditions.
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Affiliation(s)
- Anthony Wheeler
- The Neurological Institute, 2219 East 7th Street, Charlotte, NC 28204, United States.
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11
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Subclinical myasthenia gravis causing increased sensitivity to botulinum toxin therapy. J Neural Transm (Vienna) 2010; 117:1293-4. [PMID: 20953643 DOI: 10.1007/s00702-010-0481-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Accepted: 08/30/2010] [Indexed: 10/18/2022]
Abstract
In rare patients receiving botulinum toxin (BT) therapy the potency of the BT drug may be increased by pre-existent impairment of neuromuscular transmission (INT). Appropriate dose adjustment may correct for this. Subclinical INT has previously been described by us for the first time in a patient with Lambert-Eaton myasthenic syndrome. We are now describing subclinical INT for the first time in a patient with ocular myasthenia gravis. Due to its unpredictability subclinical INT may pose a risk to patients receiving BT therapy.
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Abstract
Primary focal hyperhidrosis is a disorder of idiopathic excessive sweating that typically affects the axillae, palms, soles, and face. The disorder, which affects up to 2.8% of the US population, is associated with considerable physical, psychosocial, and occupational impairments. Current therapeutic strategies include topical aluminum salts, tap-water iontophoresis, oral anticholinergic agents, local surgical approaches, and sympathectomies. These treatments, however, have been limited by a relatively high incidence of adverse effects and complications. Non-surgical treatment complications are typically transient, whereas those of surgical therapies may be permanent and significant. Recently, considerable evidence suggests that botulinum toxin type A (BTX-A) injections into hyperhidrotic areas can considerably reduce focal sweating in multiple areas without major adverse effects. BTX-A has therefore shown promise as a potential replacement for more invasive treatments after topical aluminum salts have failed. This article reviews the epidemiology, diagnosis, and management of primary focal hyperhidrosis, with an emphasis on recent research evidence supporting the use of BTX-A injections for this indication.
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Affiliation(s)
- Alexander Grunfeld
- Faculty of Medicine, University of Toronto, Women's College Hospital, Toronto, Ontario, Canada
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13
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Howard JF, Sanders DB. Chapter 12 Neurotoxicology of neuromuscular transmission. HANDBOOK OF CLINICAL NEUROLOGY 2008; 91:369-400. [DOI: 10.1016/s0072-9752(07)01512-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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14
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Singer C, Papapetropaulos S, Ayyar DR, Verma A. Botulinum toxin type A therapy in a patient with cervical dystonia and amyotrophic lateral sclerosis. Mov Disord 2007; 22:289. [PMID: 17094101 DOI: 10.1002/mds.21213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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15
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Mahajan ST, Brubaker L. Botulinum toxin: from life-threatening disease to novel medical therapy. Am J Obstet Gynecol 2007; 196:7-15. [PMID: 17240220 DOI: 10.1016/j.ajog.2006.03.108] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Revised: 02/07/2006] [Accepted: 03/18/2006] [Indexed: 10/23/2022]
Abstract
Botulinum toxin A is the newest therapy for the treatment of a variety of medical disorders caused by abnormalities of muscle activity. After successful use in other medical subspecialties, the newest applications of this potent neurotoxin are within the lower urinary tract. The toxin has evolved from a cause of fatal disease into the newest neuropharmacologic medical therapy.
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Affiliation(s)
- Sangeeta T Mahajan
- Division of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals of Cleveland, Cleveland, OH, USA
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Mahajan ST, Brubaker L. Botulinum toxin: From life-threatening disease to novel medical therapy. Am J Obstet Gynecol 2006. [DOI: 10.1016/j.ajog.2006.03.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Fasano A, Bentivoglio AR, Ialongo T, Soleti F, Evoli A. Treatment with botulinum toxin in a patient with myasthenia gravis and cervical dystonia. Neurology 2006; 64:2155-6. [PMID: 15985599 DOI: 10.1212/01.wnl.0000165997.77985.32] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- A Fasano
- Istituto di Neurologia, Università Cattolica del Sacro Cuore, Rome, Italy
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18
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Abstract
Dystonia is a syndrome of sustained involuntary muscle contractions, frequently causing twisting and repetitive movements or abnormal posturing. Cervical dystonia (CD) is a form of dystonia that involves neck muscles. However, CD is not the only cause of neck rotation. Torticollis may be caused by orthopaedic, musculofibrotic, infectious and other neurological conditions that affect the anatomy of the neck, and structural causes. It is estimated that there are between 60,000 and 90,000 patients with CD in the US. The majority of the patients present with a combination of neck rotation (rotatory torticollis or rotatocollis), flexion (anterocollis), extension (retrocollis), head tilt (laterocollis) or a lateral or sagittal shift. Neck posturing may be either tonic, clonic or tremulous, and may result in permanent and fixed contractures. Sensory tricks ('geste antagonistique') often temporarily ameliorate dystonic movements and postures. Commonly used sensory tricks by patients with CD include touching the chin, back of the head or top of the head. Patients with CD are classified according to aetiology into two groups: primary CD (idiopathic--may be genetic or sporadic) or secondary CD (symptomatic). Patients with primary CD have no evidence by history, physical examination or laboratory studies (except primary dystonia gene) of any secondary cause for the dystonic symptoms. CD is a part of either generalised or focal dystonic syndrome which may have a genetic basis, with an identifiable genetic association. Secondary or symptomatic CD may be caused by central or peripheral trauma, exposure to dopamine receptor antagonists (tardive), neurodegenerative disease, and other conditions associated with abnormal functioning of the basal ganglia. In the majority of patients with CD, the aetiology is not identifiable and the disorder is often classified as primary. Unless the aetiological investigation reveals a specific therapeutic intervention, therapy for CD is symptomatic. It includes supportive therapy and counselling, physical therapy, pharmacotherapy, chemodenervation [botulinum toxin (BTX), phenol, alcohol], and central and peripheral surgical therapy. The most widely used and accepted therapy for CD is local intramuscular injections of BTX-type A. Currently, both BTX type A and type B are commercially available, and type F has undergone testing. Pharmacotherapy, including anticholinergics, dopaminergic depleting and blocking agents, and other muscle relaxants can be used alone or in combination with other therapeutic interventions. Surgery is usually reserved for patients with CD in whom other forms of treatment have failed.
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Affiliation(s)
- M Velickovic
- Department of Neurology, The Mount Sinai Medical Center, New York, New York, 10029, USA.
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19
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Thobois S, Broussolle E, Toureille L, Vial C. Severe dysphagia after botulinum toxin injection for cervical dystonia in multiple system atrophy. Mov Disord 2001; 16:764-5. [PMID: 11481708 DOI: 10.1002/mds.1101] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
A 71-year-old woman was treated by botulinum toxin (BTX) type A injections for cervical dystonia related to a multiple system atrophy (MSA). A few days later and persisting for the next 4 months, she developed a severe dysphagia, requiring nasogastric feeding. This implicates cautious use of BTX in a case of MSA.
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Affiliation(s)
- S Thobois
- Department of Neurology, Neurological Hospital Pierre Wertheimer, Lyon, France.
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20
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Abstract
The role of botulinum toxin as a therapeutic agent is expanding rapidly in otolaryngology. Botulinum toxin is a protease that blocks the release of acetylcholine from nerve terminals. Its effects are transient and nondestructive, and largely limited to the area in which it is administered. These effects are also graded according to dose, allowing for individualized treatment of patients and disorders. Botulinum toxin has been used primarily to treat disorders of excessive or inappropriate muscle contraction. In the field of otolaryngology, these include spasmodic dysphonia, oromandibular dystonia, and blepharospasm; vocal tics and stuttering; cricopharyngeal achalasia; various tremors and tics; hemifacial spasm; temporomandibular joint disorders; and a number of cosmetic applications. Botulinum toxin treatment has recently begun to show some benefit in the control of pain from migraine and tension headache. It may also prove useful in the control of autonomic dysfunction, as in Frey syndrome, sialorrhea, and rhinorrhea. In over 20 years of use in humans, botulinum toxin has accumulated a considerable safety record, and in many cases represents relief for thousands of patients unaided by other therapy.
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Affiliation(s)
- A Blitzer
- New York Center for Voice and Swallowing Disorders, St. Luke's-Roosevelt Hospital Center, NY, USA
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21
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Affiliation(s)
- D Tarsy
- Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA
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22
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Abstract
During the initial consultation, the patient is introduced to the five basic treatment options, acknowledging that in most cases, the choice is in the patient's control. The options are 1) supportive/social treatment, 2) physical therapies, 3) oral and intrathecal pharmacotherapy, 4) injection (botulinum toxin type A ) therapy, and 5) surgical therapy. Although a patient may be an obvious candidate for a specific intervention, the patient needs to be aware of the options, including those that he or she chooses not to use. Combination therapies are often appropriate. The option of supportive therapy is applicable in nearly all situations. All patients are encouraged to join a dystonia advocacy association. To accomplish this, literature is made available to them, and the telephone number of the local dystonia chapter is provided. For most patients with focal dystonia or symptoms limited to one region, such as those with cervical dystonia, local injections of botulinum toxin type A are core treatment. For those who cannot be treated effectively with BTX-A, or for those in whom BTX-A has failed, pharmacotherapy is instituted. Pharmacotherapy can often "take the edge off" symptoms that remain after BTX-A therapy. Physical therapies are recommended as complementary treatment for most patients receiving BTX-A in an attempt to extend the benefit from BTX-A. BTX-A may substantially change motor patterns, requiring physical therapies to help the patient relearn normal postures and functional control. In refractory cases when all other measures have failed, peripheral or brain surgery is considered. With our advancing understanding of the genetics of dystonia, it is hoped that specific therapy to either halt the progression of or bring additional relief to dystonic spasms will be available shortly.
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LeWitt PA, Trosch RM. Idiosyncratic adverse reactions to intramuscular botulinum toxin type A injection. Mov Disord 1997; 12:1064-7. [PMID: 9399239 DOI: 10.1002/mds.870120637] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Three cases of adverse reactions to repeated intramuscular botulinum toxin A (BTA) injections are described: a persistent rash on the face at the site of injection, a localized anaphylactic reaction following BTA injection into one leg, and bilateral ptosis repeatedly following BTA injection into neck muscles. The mechanisms for these idiosyncratic adverse responses are not known.
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Affiliation(s)
- P A LeWitt
- Clinical Neuroscience Center, Sinai Hospital, West Bloomfield, Michigan, USA
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