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Oguz-Akarsu E, Lazrak SEH, Gullu G, Dinç Y, Saridas F, Karli N. Unusual presentations of myasthenia gravis and misdiagnosis. Sci Rep 2025; 15:7516. [PMID: 40032968 PMCID: PMC11876431 DOI: 10.1038/s41598-025-91470-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2024] [Accepted: 02/20/2025] [Indexed: 03/05/2025] Open
Abstract
Myasthenia gravis (MG) poses diagnostic challenges due to its diverse clinical presentations. Diagnosing MG remains complex despite advancements, necessitating further understanding of its diverse clinical profiles. We conducted a retrospective analysis of 290 MG cases. Patient demographics, symptomatology, and diagnostic outcomes were reviewed. Patients were categorized into two groups: those displaying classical presentations and those manifesting unusual presentations. The patients with unusual presentations were comprehensively evaluated and the demographic and clinical characteristics of the two groups were compared. In our study of 290 patients with MG, 20 presented with unusual manifestations (6.9%). These included isolated dropped head, bilateral facial weakness, distal limb weakness (e.g., foot and hand drop), weakness of limb-girdle muscles, and isolated ocular findings without ptosis. When patients were categorized into two groups based on their initial symptoms, no significant differences in demographic and clinical features were observed between the classical and unusual groups, except for a higher prevalence of anti-MuSK antibodies and more frequent administration of rituximab in patients with unusual presentations. Recognizing unusual MG presentations is crucial for timely management. Our study underscores the diverse clinical spectrum of MG, emphasizing the need for nuanced diagnostic approaches and prompt intervention.
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Affiliation(s)
- Emel Oguz-Akarsu
- Department of Neurology, Uludag School of Medicine, Bursa Uludag University, Gorukle, Bursa, Turkey.
| | - Sarra El Hamida Lazrak
- Department of Neurology, Uludag School of Medicine, Bursa Uludag University, Gorukle, Bursa, Turkey
| | - Gizem Gullu
- Department of Neurology, Uludag School of Medicine, Bursa Uludag University, Gorukle, Bursa, Turkey
| | - Yasemin Dinç
- Department of Neurology, Uludag School of Medicine, Bursa Uludag University, Gorukle, Bursa, Turkey
| | - Furkan Saridas
- Department of Neurology, Uludag School of Medicine, Bursa Uludag University, Gorukle, Bursa, Turkey
| | - Necdet Karli
- Department of Neurology, Uludag School of Medicine, Bursa Uludag University, Gorukle, Bursa, Turkey
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Zhao XL, Zheng YL, Yang CL, Wang JY, Liu Y, Du T, Zhao ZY, Duan RS, Li XL. Myasthenia gravis with tongue muscle atrophy: A case series. Heliyon 2024; 10:e30015. [PMID: 38707411 PMCID: PMC11066395 DOI: 10.1016/j.heliyon.2024.e30015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/07/2024] [Accepted: 04/18/2024] [Indexed: 05/07/2024] Open
Abstract
Here, we presented 6 patients who were admitted to our institution and diagnosed as myasthenia gravis (MG) with tongue muscle atrophy. All these 6 patients developed symptoms of bulbar muscle weakness in acetylcholine receptor antibodies positive MG (AChR-MG) (3/6), muscle-specific receptor tyrosine kinase antibodies positive MG (MuSK-MG) (1/6), and sero-negative MG (2/6). Most of patients had "triple-furrowed" tongue except for patient 2 with irregular atrophy of tongue muscle. Tongue muscle atrophy occurs in patients with MuSK-MG, AChR-MG, and sero-negative MG. Atrophied tongue muscles of five patients with MG were reversible after immunotherapy.
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Affiliation(s)
- Xue-Lu Zhao
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, PR China
| | - Yue-Liang Zheng
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, PR China
| | - Chun-Lin Yang
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, PR China
- Shandong Institute of Neuroimmunology, Jinan, 250014, PR China
- Shandong Provincial Medicine and Health Key Laboratory of Neuroimmunology, Jinan, 250014, PR China
| | - Jun-Yan Wang
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, PR China
| | - Ying Liu
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, PR China
- Shandong Institute of Neuroimmunology, Jinan, 250014, PR China
- Shandong Provincial Medicine and Health Key Laboratory of Neuroimmunology, Jinan, 250014, PR China
| | - Tong Du
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, PR China
- Shandong Institute of Neuroimmunology, Jinan, 250014, PR China
- Shandong Provincial Medicine and Health Key Laboratory of Neuroimmunology, Jinan, 250014, PR China
| | - Ze-Yu Zhao
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, PR China
| | - Rui-Sheng Duan
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, PR China
- Shandong Institute of Neuroimmunology, Jinan, 250014, PR China
- Shandong Provincial Medicine and Health Key Laboratory of Neuroimmunology, Jinan, 250014, PR China
| | - Xiao-Li Li
- Department of Neurology, the First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, 250014, PR China
- Shandong Institute of Neuroimmunology, Jinan, 250014, PR China
- Shandong Provincial Medicine and Health Key Laboratory of Neuroimmunology, Jinan, 250014, PR China
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Wang F, Cheng J, Niu X, Li L. Respiratory failure as first presentation of myasthenia gravis: a case report. J Int Med Res 2024; 52:3000605241234585. [PMID: 38443765 PMCID: PMC10916481 DOI: 10.1177/03000605241234585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/01/2024] [Indexed: 03/07/2024] Open
Abstract
Myasthenia gravis (MG) is often complicated by respiratory failure, an exacerbation known as myasthenic crisis. However, most patients with MG develop respiratory symptoms during the late course of the disease. Respiratory failure as an exclusive initial and primary complaint in patients with MG is rare and seldom reported. We herein describe a woman in her late 50s who presented with respiratory failure and was diagnosed with obesity hypoventilation syndrome at a local hospital. Her condition gradually worsened during the next 4 months and became accompanied by dysphagia. After 1 year of medical investigation, she was diagnosed in our hospital. A high level of anti-muscle-specific receptor tyrosine kinase antibody was found in her serum, and stimulation and electromyography results suggested MG. The patient's symptoms were improved by intravenous immunoglobulin and hormone therapy. This case reminds physicians to consider MG when encountering a patient who initially presents with respiratory failure.
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Affiliation(s)
- Fangming Wang
- Hebei Medical University Graduate School, Shijiazhuang, China
| | - Jinming Cheng
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Xiaoli Niu
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Litao Li
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
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Keene KR, Kan HE, van der Meeren S, Verbist BM, Tannemaat MR, Beenakker JM, Verschuuren JJ. Clinical and imaging clues to the diagnosis and follow-up of ptosis and ophthalmoparesis. J Cachexia Sarcopenia Muscle 2022; 13:2820-2834. [PMID: 36172973 PMCID: PMC9745561 DOI: 10.1002/jcsm.13089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/15/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022] Open
Abstract
Ophthalmoparesis and ptosis can be caused by a wide range of rare or more prevalent diseases, several of which can be successfully treated. In this review, we provide clues to aid in the diagnosis of these diseases, based on the clinical symptoms, the involvement pattern and imaging features of extra-ocular muscles (EOM). Dysfunction of EOM including the levator palpebrae can be due to muscle weakness, anatomical restrictions or pathology affecting the innervation. A comprehensive literature review was performed to find clinical and imaging clues for the diagnosis and follow-up of ptosis and ophthalmoparesis. We used five patterns as a framework for differential diagnostic reasoning and for pattern recognition in symptomatology, EOM involvement and imaging results of individual patients. The five patterns were characterized by the presence of combination of ptosis, ophthalmoparesis, diplopia, pain, proptosis, nystagmus, extra-orbital symptoms, symmetry or fluctuations in symptoms. Each pattern was linked to anatomical locations and either hereditary or acquired diseases. Hereditary muscle diseases often lead to ophthalmoparesis without diplopia as a predominant feature, while in acquired eye muscle diseases ophthalmoparesis is often asymmetrical and can be accompanied by proptosis and pain. Fluctuation is a hallmark of an acquired synaptic disease like myasthenia gravis. Nystagmus is indicative of a central nervous system lesion. Second, specific EOM involvement patterns can also provide valuable diagnostic clues. In hereditary muscle diseases like chronic progressive external ophthalmoplegia (CPEO) and oculo-pharyngeal muscular dystrophy (OPMD) the superior rectus is often involved. In neuropathic disease, the pattern of involvement of the EOM can be linked to specific cranial nerves. In myasthenia gravis this pattern is variable within patients over time. Lastly, orbital imaging can aid in the diagnosis. Fat replacement of the EOM is commonly observed in hereditary myopathic diseases, such as CPEO. In contrast, inflammation and volume increases are often observed in acquired muscle diseases such as Graves' orbitopathy. In diseases with ophthalmoparesis and ptosis specific patterns of clinical symptoms, the EOM involvement pattern and orbital imaging provide valuable information for diagnosis and could prove valuable in the follow-up of disease progression and the understanding of disease pathophysiology.
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Affiliation(s)
- Kevin R. Keene
- CJ Gorter MRI Center, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of NeurologyLeiden University Medical CenterLeidenThe Netherlands
| | - Hermien E. Kan
- CJ Gorter MRI Center, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
- Duchenne CenterThe Netherlands
| | - Stijn van der Meeren
- Department of OphthalmologyLeiden University Medical CenterLeidenThe Netherlands
- Orbital Center, Department of OphthalmologyAmsterdam University Medical CentersAmsterdamThe Netherlands
| | - Berit M. Verbist
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | | | - Jan‐Willem M. Beenakker
- CJ Gorter MRI Center, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of OphthalmologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Radiation OncologyLeiden University Medical CenterLeidenThe Netherlands
| | - Jan J.G.M. Verschuuren
- Department of NeurologyLeiden University Medical CenterLeidenThe Netherlands
- Duchenne CenterThe Netherlands
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Zhao S, Zhang K, Ren K, Lu J, Ma C, Zhao C, Li Z, Guo J. Clinical features, treatment and prognosis of MuSK antibody-associated myasthenia gravis in Northwest China: a single-centre retrospective cohort study. BMC Neurol 2021; 21:428. [PMID: 34732168 PMCID: PMC8567678 DOI: 10.1186/s12883-021-02439-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/14/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND AND PURPOSE To summarize the clinical characteristics of patients with muscle-specific kinase antibody-associated myasthenia gravis (MuSK-MG) and to evaluate the therapeutic responses to different treatment regimes. METHODS Eighteen MuSK-MG patients admitted in our department between October 2017 and September 2020 were included. Clinical parameters were collected and the responses to different immunosuppressive drugs were assessed by MGFA Postintervention Status (MGFA-PIS). Meanwhile, the correlation between QMG scores and MuSK antibody titers were analyzed and MuSK antibody (MuSK-ab) titers were compared before and after therapy based on different immunosuppressive treatment regimes. RESULTS Female predominance (ratio of females to males, 15:3) was evident in the study population, with the average onset age of (40.28 ± 18.57) years and the median disease course of 30.50 months (interquartile range [IQR], 17.50-44.75 months). Ocular manifestation was the most common onset symptom (11/18; 61.11%), and mild symmetrical ptosis was most frequent. Bulbar symptoms had the highest incidence of 88.89% over the entire disease course. Abnormal responses to RNS test were recorded most frequently on the musculus deltoideus (83.33%). All patients were treated with prednisone (Pred) alone or plus azathioprine (AZA), tacrolimus (TAC) or low-dose rituximab (RTX), and 17 (94.44%) of them achieved a favorable outcome defined as minimal manifestation (MM) or better. In general, an obvious positive correlation between QMG score and MuSK-ab titer (r = 0.710, P < 0.001) were found in all patients. A more significant reduction of MuSK-ab titers was observed in patients receiving TAC or RTX plus Pred than those receiving AZA plus Pred. CONCLUSIONS The prominent clinical manifestations of ocular and bulbar muscles involvements, together with abnormal RNS response mostly recorded on the musculus deltoideus and better efficacy associated with TAC or low-dose RTX plus Pred, provide a more exhaustive picture of MuSK-MG, particularly in Northwest China.
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Affiliation(s)
- Sijia Zhao
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an, 710038, Shaanxi Province, China
| | - Kai Zhang
- Department of Intensive Care Unit, Xi'an No.3 Hospital, Xi'an, 710018, Shaanxi Province, China
| | - Kaixi Ren
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an, 710038, Shaanxi Province, China
| | - Jiarui Lu
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an, 710038, Shaanxi Province, China
| | - Chao Ma
- Department of Cardiology, Tangdu Hospital, Air Force Medical University, Xi'an, 710038, Shaanxi Province, China
| | - Cong Zhao
- Department of Neurology, Air Force Medical Center of PLA, Beijing, 100142, China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an, 710038, Shaanxi Province, China.
| | - Jun Guo
- Department of Neurology, Tangdu Hospital, Air Force Medical University, Xi'an, 710038, Shaanxi Province, China.
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MRI evidence of extraocular muscle atrophy and fatty replacement in myasthenia gravis. Neuroradiology 2021; 63:1531-1538. [PMID: 34232334 DOI: 10.1007/s00234-021-02753-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/11/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE The aim of the study was to evaluate extraocular muscle (EOM) atrophy and fatty replacement in ocular myasthenia gravis (OMG) and generalized myasthenia gravis (GMG) patients with chronic and untreated ocular symptoms or with inadequate response to immunotherapy and unprovoked ocular exacerbations despite chronic immunotherapy. METHODS Nineteen patients with either OMG or GMG and 19 healthy age-matched controls underwent an orbital MRI. Visually obvious muscle atrophy and muscle fatty replacement were evaluated by two raters independently. Maximum thickness of EOM was measured. Measurements of the muscles of each participant were added up, in order to calculate the total thickness. RESULTS Eleven patients suffered from AChR-positive GMG, and 8 patients from OMG. All patients had chronic ocular symptoms or inadequate response to corticosteroids and unprovoked ocular exacerbations in spite of immunotherapy. Fatty replacement was reported in 6/19 (31.6%) patients and 0/19 (0%) controls (p = 0.02). Obvious atrophy in at least one muscle was reported in 8/19 (42.1%) patients and 1/19 (5.3%) controls (p = 0.019). Statistically significant differences between the two groups were also found in the mean total thickness, as well as in the thickness of superior recti, levator palpebrae, inferior recti, and superior oblique muscles. CONCLUSION EOM atrophy and fatty replacement were seen frequently in our series of MG patients with treatment difficulties and frequent relapses of ocular involvement.
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Zhang Z, Guan Y, Han J, Li M, Shi M, Deng H. Regional Features of MuSK Antibody-Positive Myasthenia Gravis in Northeast China. Front Neurol 2020; 11:516211. [PMID: 33123066 PMCID: PMC7566902 DOI: 10.3389/fneur.2020.516211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 08/21/2020] [Indexed: 11/17/2022] Open
Abstract
Objective: To summarize the characteristics of muscle-specific receptor tyrosine kinase antibody-positive myasthenia gravis (MuSK-MG) in Northeast China. Methods: We retrospectively collected 183 confirmed MG patients and divided them into three groups based on the type of serum antibodies: MuSK-MG (14 cases), acetylcholine receptor (AChR)-MG (130 cases), and double-seronegative (DSN)-MG (39 cases). The clinical, diagnostic, therapeutic, and prognosis data were analyzed. Results: MuSK antibody was detected in 26.7% of seronegative MG. The mean age of onset in MuSK-MG was 53.2 ± 13.6 years. Fifty percent of MuSK-MG patients with an onset symptom of pure ocular muscle weakness. The time from onset to other muscle groups' involvement and the time from onset to myasthenic crisis had no significant difference among the three groups (P > 0.05). The proportion of Osserman classification I in MuSK-MG group was lower than that in DSN-MG group. The proportion of Osserman classification IV in MuSK-MG group was higher than that in the other two groups. The incidences of other coexisting autoimmune diseases in MuSK-MG group were higher. Prognosis after the treatment of steroid combined with tacrolimus for MuSK-MG was similar to AChR-MG treated with steroid combined with an immunosuppressant agent (P > 0.05). Conclusion: Patients with MuSK-MG in Northeast China have a modestly later onset age and a proportion of patients may have a mild form of the disease with delayed disease progression. We confirmed the existence of a rare ocular MuSK-MG phenotype, a high proportion of coexisting with other autoimmune diseases, and a good response to steroids combined with tacrolimus for our MuSK-MG series.
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Affiliation(s)
- Zunwei Zhang
- Department of Neurology and Neuroscience Center, First Hospital of Jilin University, Changchun, China
| | - Yujia Guan
- Department of Neurology and Neuroscience Center, First Hospital of Jilin University, Changchun, China
| | - Jiale Han
- Department of Endocrinology, First Hospital of Jilin University, Changchun, China
| | - Mingming Li
- Department of Neurology and Neuroscience Center, First Hospital of Jilin University, Changchun, China
| | - Miao Shi
- Department of Neurology and Neuroscience Center, First Hospital of Jilin University, Changchun, China
| | - Hui Deng
- Department of Neurology and Neuroscience Center, First Hospital of Jilin University, Changchun, China
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