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Liu J, Ma J, Hong S, Jiang L, Li T. Pediatric myasthenia gravis with a combination of AChR and RyR is associated with an earlier onset and lower CSR rate: A cohort study in southwest China. Eur J Paediatr Neurol 2023; 47:1-5. [PMID: 37639776 DOI: 10.1016/j.ejpn.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/09/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The clinical manifestations and prognosis of myasthenia gravis are related to antibodies, and children are affected differently than adults. The presence of ryanodine receptor and titin antibodies in adults indicates late onset and severe disease related to thymoma, but their role in children is rarely reported. METHODS This study collected a cohort of children according to inclusion and exclusion criteria, consisting of antibody-negative, AChR-positive, and AChR with or without titin and RyR antibodies. The differences among groups in general conditions, clinical manifestation, treatment and prognosis were compared. RESULTS In total, 171 patients were included: 33 patients (19.30%) were antibody-negative, 84 patients (49.12%) were positve for AChR antibody, 22 patients (12.87%) were positve for AChR and RyR antibodies, 5 patients (2.92%) were positve for AChR and Titin antibodies, and 27 patients (15.79%) were positve for AChR, RyR and Titin antibodies. The median onset age of all the patients was 57.8 (9-177) months, and patients with AChR and RyR antibodies (p = 0.02) and AChR, RyR and Titin antibodies (p = 0.0006) had a younger onset age than patients with AChR antibodies. The rate of generalized MG and MG-ADL before treatment in the AChR-, RyR- and Titin antibody-positive groups was distinctly higher than that in the AChR antibody-positive group (p = 0.038, p = 0.0325). The rate of IVIG use in the AChR-, RyR- and Titin antibody-positive groups (p = 0.0388) was higher than that in the AChR antibody-positive group. The rate of immunosuppressant use in the AChR and RyR antibody-positive group (p = 0.0415) and in the AChR, RyR and Titin antibody-positive group (p = 0.0006) was higher than that in the AChR antibody-positive group. Plasmapheresis was performed in 1 case in the AChR-, RyR- and Titin antibody-positive groups. The CSR rate in the AChR and RyR antibody-positive group (p = 0.0423) and in the AChR, RyR and Titin antibody-positive group (p = 0.0152) was significantly lower than that in the AChR antibody-positive group. Gender, ptosis severity, and CSR time were not significantly different between groups. CONCLUSIONS We summarized one of the largest cohorts of pediatric MG patients and compared the clinical phenotype of patients with antibody-negative, AChR-positive, and AChR with or without titin and RyR antibodies. The results showed that patients with AChR and RyR antibodies had a younger onset age, a higher immunosuppressant use rate and a lower CSR rate.
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Affiliation(s)
- Jie Liu
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jiannan Ma
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Siqi Hong
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Li Jiang
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Tianyi Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.
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Yamamoto D, Imai T, Tsuda E, Hozuki T, Yamauchi R, Hisahara S, Kawamata J, Shimohama S. Effect of local cooling on excitation-contraction coupling in myasthenic muscle: Another mechanism of ice-pack test in myasthenia gravis. Clin Neurophysiol 2017; 128:2309-2317. [DOI: 10.1016/j.clinph.2017.08.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 08/17/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
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Yamamoto D, Imai T, Tsuda E, Hozuki T, Yamauchi R, Hisahara S, Kawamata J, Shimohama S. Impaired post-tetanic potentiation of muscle twitch in myasthenia gravis. Clin Neurophysiol 2015; 127:1689-1693. [PMID: 26547355 DOI: 10.1016/j.clinph.2015.10.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/06/2015] [Accepted: 10/10/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate post-tetanic potentiation of muscle twitch in myasthenia gravis (MG). METHODS Post-tetanic potentiation was evaluated by recording the compound muscle action potential (CMAP) of abductor pollicis brevis and movement-related potential (MRP) of the thumb using an accelerometer after tetanic stimulation of the median nerve at the wrist. After baseline recording, tetanic stimulation was delivered to the median nerve at a frequency of 10 Hz for 10s. The CMAP and MRP were successively recorded at baseline and at 5, 10, 30, 60, 90 and 120 s after tetanic stimulation. The chronological changes of CMAPs and MRPs were recorded bilaterally in 11 patients with MG, 9 patients with myopathies (disease controls), and 25 healthy control subjects. RESULTS Maximal acceleration of MRP was significantly elevated during 10s after tetanic stimulation without any CMAP changes in all groups. However, statistical analysis detected a significant decrease in post-tetanic potentiation of maximal acceleration of MRP in MG patients only compared to healthy controls, but not in myopathy patients, which may imply impairment of excitation-contraction coupling in MG. CONCLUSIONS Post-tetanic potentiation of muscle twitch is significantly diminished in MG, suggesting impaired excitation-contraction coupling. SIGNIFICANCE Measurement of post-tetanic potentiation using an accelerometer is a simple and sensitive method to detect impairment of excitation-contraction coupling in MG.
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Affiliation(s)
- Daisuke Yamamoto
- Department of Neurology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tomihiro Imai
- Department of Occupational Therapy, Sapporo Medical University School of Health Sciences, Sapporo, Japan.
| | - Emiko Tsuda
- Department of Neurology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | | | - Rika Yamauchi
- Department of Neurology, Sunagawa City Medical Center, Sunagawa, Japan
| | - Shin Hisahara
- Department of Neurology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Jun Kawamata
- Department of Neurology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Shun Shimohama
- Department of Neurology, Sapporo Medical University School of Medicine, Sapporo, Japan
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Nakane S. [Calcineurin inhibitors and IVIg in the treatment of myasthenia gravis]. Rinsho Shinkeigaku 2013; 53:1309-1311. [PMID: 24291970 DOI: 10.5692/clinicalneurol.53.1309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Calcineurin inhibitors (CNIs) and intravenous immunoglobulin (IVIg) are immunomodulatory treatments used to treat patients with myasthenia gravis (MG). The objective of this study was to describe the clinical features of MG treated with CNIs or IVIg. To characterise the clinical features of myasthenic symptoms in MG treated with CNIs compared with MG treated without CNIs. Patients with MG (676 cases) underwent a multidisciplinary clinical examination (quantitative MG score for disease severity (QMG score), MG composite, etc), and we extensively reviewed the case histories with current clinical and laboratory evaluations. We confirmed CNIs were safe and effective in the treatment of MG in association with reduction of corticosteroids. IVIg have efficacy in reducing QMG score in patients with moderate to severe MG.
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Affiliation(s)
- Shunya Nakane
- Department of Clinical Research, Nagasaki Kawatana Medical Center
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Haran M, Schattner A, Mate A, Starobin D, Haran G, Shtalrid M. Can a rare form of myasthenia gravis shed additional light on disease mechanisms? Clin Neurol Neurosurg 2012; 115:562-6. [PMID: 22854280 DOI: 10.1016/j.clineuro.2012.06.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 06/26/2012] [Accepted: 06/30/2012] [Indexed: 02/04/2023]
Abstract
A healthy 43-year-old physician developed gradually progressive and fluctuating fatigable muscle weakness involving ocular, limb, bulbar and respiratory muscles, with episodic acute respiratory failure, eventually necessitating intermittent non-invasive respiratory support (NIV). A mild short episode occurred 15 years earlier with complete resolution. Electromyography (EMG) studies and acetylcholine receptor (AchR) antibodies were repeatedly non-diagnostic. The diagnosis of myasthenia gravis (MG) was finally confirmed by direct measurement of diaphragmatic strength using magnetic nerve stimulation providing clear cut evidence of significant fatigable weakness and the demonstration of muscle-specific kinase (MuSK) serum antibodies using a novel cell-based assay. The cluster of several atypical features and lack of response to commonly used treatment modalities prompted a search for a unifying mechanism and better understanding of the underlying pathophysiology. Review of the literature suggested a possible impairment of excitation-contraction coupling with malfunction of a signaling protein downstream to the AchR, without an accompanying impairment of electrical transmission. This postulated mechanism, resulting in a disturbance of calcium signaling, explained the unusual features in this patient's illness and led to treatment with salbutamol and ephedrine and to significant symptomatic improvement not achieved by any other treatment.
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Affiliation(s)
- Michal Haran
- Hematology Institute, Kaplan Medical Center, Rehovot, Hebrew University Hadassah Medical School, Jerusalem, Israel
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Contribution of anti-ryanodine receptor antibody to impairment of excitation–contraction coupling in myasthenia gravis. Clin Neurophysiol 2012; 123:1242-7. [DOI: 10.1016/j.clinph.2011.10.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 09/01/2011] [Accepted: 10/02/2011] [Indexed: 11/21/2022]
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Kauling ALC, de Almeida MCS, Locks GDF, Brunharo GM. Myasthenia gravis: two case reports and review of the literature. Rev Bras Anestesiol 2011; 61:748-63. [PMID: 22063376 DOI: 10.1016/s0034-7094(11)70084-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 02/21/2011] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Myasthenia gravis (MG) is an autoimmune neurologic disease that affects the postsynaptic portion of the neuromuscular junction. It represents a challenge for anesthesiologists due to the diversity of disease manifestations and possibility of postoperative respiratory complications. The objective of this study was to demonstrate the importance of adequate monitoring of the neuromuscular blockade (NMB) due to the multiple presentations of MG. CONTENTS In this paper we report two cases of patients with MG. The first patient presented with the classical sensitivity to the neuromuscular blocker (NMB) and the second had a similar response to that of a normal patient. The literature review will be restricted to disease characteristics, while the description of its pathophysiology will focus on its reactions to NMB. CONCLUSIONS We suggest that, due to the multiple presentation and treatment of MG, neuromuscular transmission monitors are fundamental when using NMB.
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Suzuki S, Utsugisawa K, Nagane Y, Suzuki N. Three types of striational antibodies in myasthenia gravis. Autoimmune Dis 2011; 2011:740583. [PMID: 21785709 PMCID: PMC3139883 DOI: 10.4061/2011/740583] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 06/03/2011] [Indexed: 11/20/2022] Open
Abstract
Myasthenia gravis (MG) is caused by antibodies that react mainly with the acetylcholine receptor on the postsynaptic site of the neuromuscular junction. A wide range of clinical presentations and associated features allow MG to be classified into subtypes based on autoantibody status. Striational antibodies, which react with epitopes on the muscle proteins titin, ryanodine receptor (RyR), and Kv1.4, are frequently found in MG patients with late-onset and thymoma. Antititin and anti-RyR antibodies are determined by enzyme-linked immunosorbent assay or immunoblot. More recently, a method for the detection of anti-Kv1.4 autoantibodies has become available, involving 12-15% of all MG patients. The presence of striational antibodies is associated with more severe disease in all MG subgroups. Anti-Kv1.4 antibody is a useful marker for the potential development of lethal autoimmune myocarditis and response to calcineurin inhibitors. Detection of striational antibodies provides more specific and useful clinical information in MG patients.
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Affiliation(s)
- Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kimiaki Utsugisawa
- Department of Neurology, Hanamaki General Hospital, Hanamaki 025-0075, Japan
| | - Yuriko Nagane
- Department of Neurology, Hanamaki General Hospital, Hanamaki 025-0075, Japan
| | - Norihiro Suzuki
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
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In response to “current approach to seronegative myasthenia” by Z. Argov. J Neurol 2011; 258:164-5. [DOI: 10.1007/s00415-010-5826-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Accepted: 11/01/2010] [Indexed: 11/26/2022]
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It’s not the end: Physiologic assessment of E–C coupling of muscle. Clin Neurophysiol 2010; 121:994-5. [DOI: 10.1016/j.clinph.2010.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Accepted: 02/12/2010] [Indexed: 11/16/2022]
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Tsuda E, Imai T, Hozuki T, Yamauchi R, Saitoh M, Hisahara S, Yoshikawa H, Motomura M, Shimohama S. Correlation of bite force with excitation–contraction coupling time of the masseter in myasthenia gravis. Clin Neurophysiol 2010; 121:1051-8. [DOI: 10.1016/j.clinph.2010.01.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 01/22/2010] [Accepted: 01/27/2010] [Indexed: 10/19/2022]
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Abstract
Between 1940 and 2000 a total of 1976 patients with myasthenia gravis (MG) were studied. Diagnosis was made by improvement in weakness after anticholinesterase medication. The historical developments in diagnosis and treatment of MG are reviewed. We analyzed the clinical course of MG as influenced by age, gender, thymectomy, thymomectomy, and the presence of antibodies to acetylcholine receptors (AChR). The clinical course of MG was significantly influenced by age and gender, and these need special attention in managing patients. The most severe level of weakness and high mortality occurred during the first 1 to 2 years of the disease, after which many patients experienced improvement. For treating MG patients the usefulness of thymectomy remains to be proven, and novel drugs need to be developed to increase the number as well as normal functioning of the AChRs and other components of the neuromuscular system.
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Affiliation(s)
- David Grob
- Department of Medicine, Maimonides Medical Center, Brooklyn, New York 11219, USA
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Aarli JA, Gilhus NE, Romi F, Skeie GO. Titin and ryanodine receptor antibodies and neuromuscular involvement in myasthenia gravis. FUTURE NEUROLOGY 2008. [DOI: 10.2217/14796708.3.1.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Of sera of patients with myasthenia gravis (MG), 30% contains titin and ryanodine receptor (RyR) antibodies. In early-onset MG (i.e., before 50 years of age), the presence of titin antibodies strongly suggests a thymoma. Late-onset MG comprises one MG group, characterized by a broad antimuscle immune response, including both titin and the acetylcholine receptor (AChR). Another group is preferentially associated with the HLA-A3, B7 and DRw2 antigens, representing a delayed early-onset of the disease that has a selective AChR immune response. The presence of titin and RyR antibodies is associated with more severe disease. Titin antibodies may, in some patients with rippling muscle disease, affect the contractile machinery of myofibers, thereby affecting their mechanical sensitivity. It is not known whether this occurs in MG. RyR antibodies may impair excitation–contraction coupling and contribute to muscle weakness in MG patients. Titin antibodies may serve as tumor markers in early-onset MG patients.
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Affiliation(s)
- Johan A Aarli
- University of Bergen, Department of Clinical Medicine, 5021 Bergen, Norway
| | - Nils Erik Gilhus
- University of Bergen, Department of Clinical Medicine, and, Department of Neurology, Haukeland University Hospital, 5021 Bergen, Norway
| | - Fredrik Romi
- Haukeland University Hospital, Department of Neurology, 5021 Bergen, Norway
| | - Geir Olve Skeie
- University of Bergen, Department of Clinical Medicine, and, Department of Neurology, Haukeland University Hospital, 5021 Bergen, Norway
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