1
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Igoe A, Merjanah S, Harley ITW, Clark DH, Sun C, Kaufman KM, Harley JB, Kaelber DC, Scofield RH. Association between systemic lupus erythematosus and myasthenia gravis: A population-based National Study. Clin Immunol 2024; 260:109810. [PMID: 37949200 DOI: 10.1016/j.clim.2023.109810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are autoimmune diseases. Previous case reports and case series suggest an association may exist between these diseases, as well as an increased risk of SLE after thymectomy for MG. We undertook this study to determine whether SLE and MG were associated in large cohorts. METHODS We searched the IBM Watson Health Explorys platform and the Department of Veterans Affairs Million Veteran Program (MVP) database for diagnoses of SLE and MG. In addition, we examined subjects enrolled in the Lupus Family Registry and Repository (LFRR) as well as controls for a diagnosis of MG. RESULTS Among 59,780,210 individuals captured in Explorys, there were 25,750 with MG and 65,370 with SLE. 370 subjects had both. Those with MG were >10 times more likely to have SLE than those without MG. Those with both diseases were more likely to be women, African American, and at a younger age than MG subjects without SLE. In addition, the MG patients who underwent thymectomy had an increased risk of SLE compared to MG patients who had not undergone thymectomy (OR 3.11, 95% CI: 2.12 to 4.55). Autoimmune diseases such as pernicious anemia and miscellaneous comorbidities such as chronic kidney disease were significantly more common in MG patients who developed SLE. In the MVP, SLE and MG were also significantly associated. Association of SLE and MG in a large SLE cohort with rigorous SLE classification confirmed the association of SLE with MG at a similar level. CONCLUSION While the number of patients with both MG and SLE is small, SLE and MG are strongly associated together in very large databases and a large SLE cohort.
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Affiliation(s)
- Ann Igoe
- OhioHealth Hospital, Rheumatology Department, Mansfield, OH 44903, USA
| | - Sali Merjanah
- Boston University Medical Center, Section of Rheumatology, Department of Medicine, Boston, MA 02118, USA
| | - Isaac T W Harley
- Division of Rheumatology, Departments of Medicine and Immunology/Microbiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; Medicine Service, Rheumatology Section, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO 80045, USA
| | - Dennis H Clark
- Research Service, US Department of Veterans Affairs Medical Center, Cincinnati, OH, USA
| | - Celi Sun
- Research Service, US Department of Veterans Affairs Medical Center, Oklahoma City, OK 73104, USA
| | - Kenneth M Kaufman
- Research Service, US Department of Veterans Affairs Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - John B Harley
- Research Service, US Department of Veterans Affairs Medical Center, Cincinnati, OH, USA; Cincinnati Education and Research for Veterans Foundation, Cincinnati, OH, USA
| | - David C Kaelber
- Departments of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine and The Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH 44109, USA
| | - R Hal Scofield
- Research Service, US Department of Veterans Affairs Medical Center, Oklahoma City, OK 73104, USA; Department of Medicine, University of Oklahoma Health Sciences Center, Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, and Medical/Research Service, and Medicine Service, US Department of Veterans Affairs Medical Center, Oklahoma City, OK 73104, USA.
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2
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Zhu Y, Wang B, Hao Y, Zhu R. Clinical features of myasthenia gravis with neurological and systemic autoimmune diseases. Front Immunol 2023; 14:1223322. [PMID: 37781409 PMCID: PMC10538566 DOI: 10.3389/fimmu.2023.1223322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/23/2023] [Indexed: 10/03/2023] Open
Abstract
Multiple reports on the co-existence of autoimmune diseases and myasthenia gravis (MG) have raised considerable concern. Therefore, we reviewed autoimmune diseases in MG to explore their clinical presentations and determine whether the presence of autoimmune diseases affects the disease severity and treatment strategies for MG. We reviewed all the major immune-mediated coexisting autoimmune conditions associated with MG. PubMed, Embase and Web of Science were searched for relevant studies from their inception to January 2023. There is a higher frequency of concomitant autoimmune diseases in patients with MG than in the general population with a marked risk in women. Most autoimmune comorbidities are linked to AChR-MG; however, there are few reports of MuSK-MG. Thyroid disorders, systemic lupus erythematosus, and vitiligo are the most common system autoimmune diseases associated with MG. In addition, MG can coexist with neurological autoimmune diseases, such as neuromyelitis optica (NMO), inflammatory myopathy (IM), multiple sclerosis (MS), and autoimmune encephalitis (AE), with NMO being the most common. Autoimmune diseases appear to develop more often in early-onset MG (EOMG). MS coexists more commonly with EOMG, while IM coexists with LOMG. In addition, MG complicated by autoimmune diseases tends to have mild clinical manifestations, and the coexistence of autoimmune diseases does not influence the clinical course of MG. The clinical course of neurological autoimmune diseases is typically severe. Autoimmune diseases occur most often after MG or as a combined abnormality; therefore, timely thymectomy followed by immunotherapy could be effective. In addition, thymoma-associated AChR MG is associated with an increased risk of AE and IM, whereas NMO and MS are associated with thymic hyperplasia. The co-occurrence of MG and autoimmune diseases could be attributed to similar immunological mechanisms with different targets and common genetic factor predisposition. This review provides evidence of the association between MG and several comorbid autoimmune diseases.
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Affiliation(s)
| | | | | | - Ruixia Zhu
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
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3
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Dar S, Koirala S, Khan A, Bellary MD, Patel AV, Mathew B, Singh R, Baigam N, Razzaq W, Abdin ZU, Khawaja UA. A Comprehensive Literature Review on Managing Systemic Lupus Erythematosus: Addressing Cardiovascular Disease Risk in Females and Its Autoimmune Disease Associations. Cureus 2023; 15:e43725. [PMID: 37727166 PMCID: PMC10505685 DOI: 10.7759/cureus.43725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/18/2023] [Indexed: 09/21/2023] Open
Abstract
This review aimed to evaluate the mechanism of premature cardiovascular disease (CVD) in systemic lupus erythematosus (SLE) patients, particularly in the female population, and emphasize the need for early management interventions; explore the association between SLE and two autoimmune diseases, myasthenia gravis (MG) and antiphospholipid antibody syndrome (APS), and their management strategies; and evaluate the effectiveness of pharmacological and non-pharmacological interventions in managing SLE, focusing on premenopausal females, females of childbearing age, and pregnant patients. We conducted a comprehensive literature review to achieve these objectives using various databases, including PubMed, Google Scholar, and Cochrane. The collected data were analyzed and synthesized to provide an evidence-based overview of SLE, its management strategies as an independent disease, and some disease associations. The treatment should be focused on remission, preventing organ damage, and improving the overall quality of life (QOL). Extensive emphasis should also be focused on diagnosing SLE and concurrent underlying secondary diseases timely and managing them appropriately.
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Affiliation(s)
- Saleha Dar
- Department of Adult Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sabina Koirala
- Department of Medicine, Gandaki Medical College, Pokhara, NPL
| | - Arooba Khan
- Department of Internal Medicine, Khyber Medical College, Peshawar, PAK
| | | | - Arya V Patel
- Department of Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Bejoi Mathew
- Department of Internal Medicine, Sri Devaraj Urs Medical College, Kolar, IND
| | - Rahul Singh
- Department of Medicine, Armed Forces Medical College, Pune, IND
| | - Nahida Baigam
- Department of Medicine, Association of Physicians of Pakistani Descent of North America (APPNA), Westmont, USA
| | - Waleed Razzaq
- Department of Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Department of Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Uzzam Ahmed Khawaja
- Department of Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Department of Clinical and Translational Research, Dr. Ferrer BioPharma, South Miami, USA
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4
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Anti-dsDNA Is Associated with Favorable Prognosis in Myasthenia Gravis: A Retrospective Study. Acta Neurol Scand 2023. [DOI: 10.1155/2023/8939083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Objectives. To investigate the presence of serum antinuclear antibody (ANA) and anti-double-stranded DNA antibody (anti-dsDNA) in patients with myasthenia gravis (MG) and analyze the clinical characteristics and prognostic factors associated with MG. Methods. We retrospectively enrolled 363 patients with MG and analyzed the clinical characteristics and follow-up data between patients positive and negative for ANA and anti-dsDNA. We defined a Myasthenia Gravis Activities of Daily Living (MG-ADL) reduction as a main prognosis predictor and used logistic regression to determine independent factors associated with prognosis. We built a nomogram to predict prognosis and evaluate the internal validity of the model. Results. Ninety-eight (27.0%) patients were positive for ANA, and 51 (14.0%) were positive for anti-dsDNA. Patients positive for ANA and anti-dsDNA antibodies tended to be female and positive for acetylcholine receptor antibody (AChR-Ab). The rate of thymoma was higher in anti-dsDNA-positive patients with MG (p-dsDNA-MG) than in patients negative for anti-dsDNA (49.0% vs. 26.0%,
), and p-dsDNA-MG was associated with reduced MG-ADL score. Regression analysis showed that except for age of onset (
,
,
), anti-dsDNA (
,
,
), ptosis (
,
,
), and eye movement disorder (
,
,
) were independent predictive factors of a favorable prognosis of MG. These predictors were used to generate a nomogram with an excellent predictive value. Conclusions. Being female and the presence of AChR-Ab were features of ANA- or anti-dsDNA-positive MG. The presence of anti-dsDNA was associated with a favorable prognosis of MG.
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5
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Xu Y, Zhang Y, Hu H, Tan J, Wu B. Systemic lupus erythematosus after delivery and myasthenia gravis with COL6A1 gene mutation: A case report. EUR J INFLAMM 2022. [DOI: 10.1177/20587392211066424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The coexistence of systemic lupus erythematosus (SLE) and myasthenia gravis (MG) is rarely reported, especially the appearance of SLE before MG. In addition to the production of autoantibodies after thymectomy, gene mutation may be an important contributing factor to the overlap of SLE and MG. Here, we report a case of a female patient diagnosed with SLE before MG and found to carry the heterozygous variation COL6A1 c. 2608G>A. We propose that this gene variation weakens the function of COL6A1 and indirectly activates STAT1, resulting in the phenotype of these two autoimmune diseases. This report suggests that it is feasible to explore common pathogenic genes in SLE and MG through future large-scale research.
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Affiliation(s)
- Yanqiu Xu
- College of Traditional Chinese Medicine, Chongqing Medical University, Chongqing, China
- Department of Rheumatology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Ying Zhang
- Department of Rheumatology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Hongming Hu
- Department of Rheumatology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Jie Tan
- Department of Rheumatology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Bin Wu
- College of Traditional Chinese Medicine, Chongqing Medical University, Chongqing, China
- Department of Rheumatology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing, China
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6
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Asociación de miastenia gravis y lupus eritematoso sistémico: aportación de 5 casos y revisión de PubMed. Neurologia 2021. [DOI: 10.1016/j.nrl.2020.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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7
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Myasthenia gravis and systemic lupus erythematosus: presentation of 5 cases and PubMed review. NEUROLOGÍA (ENGLISH EDITION) 2021; 36:556-557. [DOI: 10.1016/j.nrleng.2020.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/26/2020] [Indexed: 11/23/2022] Open
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8
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Kobza A, Keenan M, Ivory C. Mixed connective tissue disease after thymectomy in refractory myasthenia gravis. Rheumatol Int 2021; 42:2077-2084. [PMID: 34432146 DOI: 10.1007/s00296-021-04976-3] [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: 06/30/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
Connective tissue diseases, including systemic lupus erythematosus (SLE) and systemic sclerosis are classic models of autoimmunity; diseases with large-scale loss of tolerance and subsequent development of pathogenic autoreactive lymphocytes and tissue targeting autoantibodies. Here we report a case of mixed connective tissue disease, with features of systemic lupus erythematosus and systemic sclerosis developing in a patient 10 years post thymectomy for myasthenia gravis. The patient developed acute cutaneous lupus, Raynaud's with digital ulcers, arthritis and lymphopenia. Her myasthenia continued to be resistant to treatment and her rheumatic disease progressed despite aggressive therapy. We performed a database search of MEDLINE, EMBASE, Scopus, and Web of Science for articles of similar cases post thymectomy from inception to August 2021, using the terms "systemic lupus erythematosus" (or systemic sclerosis, or connective tissue disease) and "myasthenia gravis" and "thymectomy". We identified 41 cases, 28 of SLE post thymectomy, 8 related to systemic sclerosis, 5 with mixed connective tissue disease and highlighted their different presentation and serology. We explore the role of the thymus, tolerance and myasthenia gravis in the development of connective tissue disease. This highlights the complexity of concurrent autoimmune diseases and their autoantibodies.
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Affiliation(s)
- Alexandra Kobza
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Marissa Keenan
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Rheumatology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Catherine Ivory
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Division of Rheumatology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada. .,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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9
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Ali M, Riad M, Adhikari P, Bhattarai S, Gupta A, Ali E, Mostafa JA. Association Between Myasthenia Gravis and Systemic Lupus Erythematosus as a Comorbid State. Cureus 2021; 13:e14719. [PMID: 34055558 PMCID: PMC8158067 DOI: 10.7759/cureus.14719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are autoimmune states which have presentational similitude. Both conditions test serologically positive for anti-nuclear antibodies and require exceptional differential diagnostic acumen to segregate one from the other. The hypothesized factors provoking these diseases may be immunological, genetic, hormonal, or environmental and can be better understood by large-scale controlled epidemiological studies. Biochemical factors such as variation in CXC (an α chemokine subfamily), CXCL13, and granulocyte-macrophage colony-stimulating factor levels are assumed to play a pivotal role in the pathogenesis of SLE and MG; however, further studies are required to understand their exact mechanism and effect on the underlying autoimmune diseases.
Following this, another precipitating factor for this overlap is believed to be thymectomy which is performed to eliminate MG symptoms. Although thymectomy is the effective treatment modality in MG patients, other findings and data support the view that this procedure may lead to the development of other autoimmune states such as SLE. It is evident from previously published data and case reports that patients with one autoimmune disease who underwent thymectomy contracted SLE and became more susceptible to other autoimmune diseases compared to the general population. Post-thymectomy follow-up of patients provides us with mechanistic clues for understanding the development of SLE-MG overlap; hence, in MG patients who have undergone thymectomy, any clinical and immune serological SLE suspicion should be carefully evaluated.
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Affiliation(s)
- Moeez Ali
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mohamed Riad
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Prakash Adhikari
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Sanket Bhattarai
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ashish Gupta
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Eiman Ali
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jihan A Mostafa
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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10
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Raut S, Reddy I, Sahi FM, Masood A, Malik BH. Association Between Systemic Lupus Erythematosus and Myasthenia Gravis: Coincidence or Sequelae? Cureus 2020; 12:e8422. [PMID: 32642338 PMCID: PMC7336596 DOI: 10.7759/cureus.8422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease and myasthenia gravis (MG) is an organ-specific autoimmune disease, both may exhibit positive anti-nuclear antibodies and a female preponderance. They may have similar features and can coexist in a patient or precede one another. This review article is based on electronic searches using PubMed as the primary database. Most of the articles used for this review were published in the last ten years with the exception of seven articles which were from 1995-2009. No guidelines have been followed. A total of 55 research articles were found related to the topic of this review article, and further scanning was done to eliminate some articles that did not meet the criteria. The coexistence of autoimmune diseases has been reported in many cases. The prevalence of a second autoimmune disease is higher among patients with a primary diagnosis of autoimmune disease than the general population. The prevalence of SLE in MG patients or vice-versa is greater than the general population. The association has been hypothesized to many mechanisms: thymectomy resulting in loss of central tolerance and generation of autoantibodies, regulatory T cell dysfunction, the dysregulated function of Fas receptor (CD95), anti-malarial drugs directly affecting the neuromuscular junction, the role of chemokine CXCL13 and GM-CSF in the pathogenesis. The association is rare, and the presence of one should be closely followed for further progression into other diseases. More research work needs to be done for a clear conclusion.
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Affiliation(s)
- Sumit Raut
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ishani Reddy
- Psychiatry and Behavioral Sciences, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Faryal Mustansir Sahi
- Dermatology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Ayesha Masood
- General Surgery, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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11
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Deya-Martinez A, Flinn AM, Gennery AR. Neonatal thymectomy in children-accelerating the immunologic clock? J Allergy Clin Immunol 2020; 146:236-243. [PMID: 32169378 DOI: 10.1016/j.jaci.2020.02.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/25/2020] [Accepted: 02/26/2020] [Indexed: 12/29/2022]
Abstract
The thymus is critical for central tolerance and diverse T-lymphocyte repertoire development, to provide lifelong defense against pathogens while maintaining self-tolerance. Peak thymic output occurs in utero, during infancy, and in early childhood, diminishing throughout life. Infants with congenital heart disease requiring sternotomy often undergo thymectomy to clear the surgical field. The long-term effects of early thymectomy are just being appreciated. Many patients remain asymptomatic despite immunologic findings mirroring those of immunosenescence. Few develop increased infection or lymphoreticular malignancy risk. When considering the effects of infant thymectomy, patients with partial DiGeorge syndrome or hypomorphic recombination-activating gene (RAG) mutations may be instructive. These patients are lymphocytopenic, with increased early-onset infection and autoimmunity risk that is not seen in most patients who underwent thymectomy during infancy. The thymic structure of patients with partial DiGeorge syndrome or hypomorphic RAG is abnormal, with disrupted architecture inclining to perturbation of central tolerance. Similar findings may be seen in patients with myasthenia gravis, although disrupted peripheral tolerance may play a greater role in autoimmunity development. In conclusion, thymectomy during infancy may increase future risk of infection or autoimmunity, with premature immunosenescence mediated through disruption of central and peripheral tolerance mechanisms initiated by early cessation or diminution of thymic output. Ideally, some thymic tissue should be preserved at the time of surgery.
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Affiliation(s)
- Angela Deya-Martinez
- Functional Unit of Clinical Immunology and Primary Immunodeficiencies, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, University of Barcelona, Pediatric Research Institute Sant Joan de Déu, Barcelona, Spain
| | - Aisling M Flinn
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Childrens' Hospital, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Childrens' Hospital, Newcastle upon Tyne, United Kingdom; Primary Immunodeficiency Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
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12
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Diestro JDB, Dorotan MKC, Andal VMD, Tomas AB, Geocadin RG, Collantes MEV. Ischaemic stroke in a patient with myasthaenic crisis and antiphospholipid antibody syndrome. BMJ Case Rep 2019; 12:12/8/e231239. [PMID: 31466961 DOI: 10.1136/bcr-2019-231239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
While autoimmune diseases have been frequently found to coexist in the same patients, the co-occurrence of myasthaeniagravis and antiphospholipid antibody syndrome (APAS) has only been reported in eight cases. We present a case of a 46-year-old Filipina who developed ischaemic stroke while admitted at the neurocritical unit for myasthaenic crisis. She was successfully thrombolysed with intravenous recombinant tissue plasminogen activator (rTPA), given a regimen of intravenous Ig and a dose of cyclophosphamide prior to discharge. Extensive workup revealed APAS to be the aetiology of her stroke. Twenty-one months into her follow-up, she is doing well with a modified Rankin Score of 0. Our case suggests that rTPA followed by immunomodulators may be given safely in myasthaenic crisis patients who develop ischaemic stroke. We emphasise the importance of doing a comprehensive neurological evaluation in agitated patients in the critical care unit.
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Affiliation(s)
- Jose Danilo B Diestro
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Maria Kristina C Dorotan
- Department of Neurology, Lewis Katz School ofMedicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Vida Margarette D Andal
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Arnolfo B Tomas
- Department of Medicine, College of Medicine and Philippines General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Romergryko G Geocadin
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ma Epifania V Collantes
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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