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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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Di Stefano V, Iacono S, Militello M, Leone O, Rispoli MG, Ferri L, Ajdinaj P, Lanza P, Lupica A, Crescimanno G, Monastero R, Di Muzio A, Brighina F. Comorbidity in myasthenia gravis: multicentric, hospital-based, and controlled study of 178 Italian patients. Neurol Sci 2024:10.1007/s10072-024-07368-0. [PMID: 38383750 DOI: 10.1007/s10072-024-07368-0] [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: 09/30/2023] [Accepted: 01/27/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disorder with fluctuating weakness that causes significant disability and morbidity. Comorbidities may influence the course of MG, particularly in specific subgroups. The aim of this study is to investigate the frequency of comorbidities in MG patients compared to healthy controls (HC) and to evaluate their distribution according to age at disease onset, sex, and disease severity. METHODS MG patients attending the University Hospital "Paolo Giaccone" in Palermo and "SS Annunziata" Hospital in Chieti were enrolled; HC were enrolled from the general population. Non-parametric statistics and logistic regression were used to assess the association of specific comorbidities according to age at disease onset, sex, disease subtypes, and severity of the disease. RESULTS A total of 356 subjects were included in the study: 178 MG patients (46% F; median age 60 years [51-71]) and 178 sex- and age-matched HC (46% F, median age 59 years [50-66]). Overall, 86% of MG patients and 76% of HC suffered from comorbidities, and MG patients had a higher number of comorbidities compared to HC. Patients with late-onset suffered from more comorbidities than those with early-onset MG. Hypertension was more common in male patients with MG, while thymic hyperplasia, osteoporosis, and autoimmune diseases were more common in females. Respiratory disorders and thymoma were more common in patients with more severe disease (p < 0.05 for all comparisons). CONCLUSION MG patients, particularly those with late onset, showed a higher prevalence of comorbidities than HC. Assessment of comorbidities in MG is an essential issue to identify the appropriate treatment and achieve the best management.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Salvatore Iacono
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Massimiliano Militello
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Olga Leone
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | | | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Paola Ajdinaj
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Placido Lanza
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Antonino Lupica
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
| | - Grazia Crescimanno
- Institute for Biomedical Research and Innovation, National Research Council of Italy, Palermo, Italy
| | - Roberto Monastero
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy.
| | - Antonio Di Muzio
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience, and Advanced Diagnostic (BIND), University of Palermo, Palermo, Italy
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Baptista A, Brière G, Baudot A. Random walk with restart on multilayer networks: from node prioritisation to supervised link prediction and beyond. BMC Bioinformatics 2024; 25:70. [PMID: 38355439 PMCID: PMC10865648 DOI: 10.1186/s12859-024-05683-z] [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: 10/18/2023] [Accepted: 01/29/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Biological networks have proven invaluable ability for representing biological knowledge. Multilayer networks, which gather different types of nodes and edges in multiplex, heterogeneous and bipartite networks, provide a natural way to integrate diverse and multi-scale data sources into a common framework. Recently, we developed MultiXrank, a Random Walk with Restart algorithm able to explore such multilayer networks. MultiXrank outputs scores reflecting the proximity between an initial set of seed node(s) and all the other nodes in the multilayer network. We illustrate here the versatility of bioinformatics tasks that can be performed using MultiXrank. RESULTS We first show that MultiXrank can be used to prioritise genes and drugs of interest by exploring multilayer networks containing interactions between genes, drugs, and diseases. In a second study, we illustrate how MultiXrank scores can also be used in a supervised strategy to train a binary classifier to predict gene-disease associations. The classifier performance are validated using outdated and novel gene-disease association for training and evaluation, respectively. Finally, we show that MultiXrank scores can be used to compute diffusion profiles and use them as disease signatures. We computed the diffusion profiles of more than 100 immune diseases using a multilayer network that includes cell-type specific genomic information. The clustering of the immune disease diffusion profiles reveals shared shared phenotypic characteristics. CONCLUSION Overall, we illustrate here diverse applications of MultiXrank to showcase its versatility. We expect that this can lead to further and broader bioinformatics applications.
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Affiliation(s)
- Anthony Baptista
- School of Mathematical Sciences, Queen Mary University of London, London, UK.
- The Alan Turing Institute, London, UK.
| | | | - Anaïs Baudot
- INSERM, MMG, Turing Center for Living Systems, Aix-Marseille Univ, Marseille, France.
- Barcelona Supercomputing Center, Barcelona, Spain.
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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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Peripheral nervous system adverse events associated with immune checkpoint inhibitors. J Neurol 2023; 270:2975-2986. [PMID: 36800019 DOI: 10.1007/s00415-023-11625-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) represent an effective cancer immunotherapy yet are associated with immune-related adverse events (irAEs). The aim of this study was to characterize irAEs involving the peripheral nervous system (PNS-irAEs) in a real-world cohort of ICI-treated patients. METHODS Cancer patients treated with ICIs between January 2014 and March 2022 were included. Patients with PNS-irAEs were identified and divided into two groups: (1) cranial/peripheral neuropathies and (2) myasthenia gravis (MG) and/or myositis. Clinical characteristics and outcomes, measured with the modified Rankin Scale (mRS), were compared among the two groups. RESULTS Among 920 ICI-treated patients, 20 patients (2.17%) developed a PNS-irAEs. The median latency from ICI exposure was 8.8 weeks and the median time from onset to clinical nadir was 3.5 weeks. Eleven patients developed a neuropathy: polyneuropathy (n = 4), cranial neuropathy (n = 3), small-fiber neuropathy (n = 3), brachial plexopathy (n = 1). Nine patients presented MG and/or myositis: concomitant MG and myositis (n = 6), isolated myositis (n = 2), exacerbation of MG (n = 1). Immunosuppressive treatment and/or ICI withdrawal determined a significant clinical improvement, expressed by a mRS reduction, in the neuropathy group (p = 0.004), but not in the MG/myositis group (p = 0.11). Overall, death due to irAEs occurred in four patients (20%), all with MG/myositis. Compared to patients with neuropathies, those with MG/myositis had a shorter latency onset (p = 0.036), developed more frequently concomitant non-neurologic irAEs (p = 0.028) and showed a higher mortality rate (p = 0.026). CONCLUSIONS In our large cohort of ICI-treated patients, 2.17% developed PNS-irAEs. Compared to ir-neuropathies, ir-MG/myositis tend to occur earlier from ICI exposure and present a worse response to treatment and a higher mortality.
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Maaroufi A, Assoufi N, Essaoudi MA, Fatihi J. Thymoma may explain the confusion: a case report. J Med Case Rep 2021; 15:616. [PMID: 34911585 PMCID: PMC8675449 DOI: 10.1186/s13256-021-03178-6] [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: 03/24/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022] Open
Abstract
Background The association of inflammatory myopathy and myasthenia gravis is a rarely described entity whose clinical presentation has always been intriguing because of the great clinical similarity between these two pathologies. The presence of a thymic pathology often explains this combination, whose mechanisms are very complex. Case presentation A 56-year-old woman of North African origin, was hospitalized to explore the Raynaud phenomenon associated with proximal muscle weakness, pain, and arthralgia. There was no rash, and neuromuscular examination had revealed proximal tetraparesis and mild neck weakness. Tendon reflexes were normal. There was no abnormal nail fold capillaroscopy. A significant titer of muscle enzymes had been shown on blood tests, and autoimmune screening for myositis-specific and myositis-associated autoantibodies was negative. Electromyography had shown a myopathic pattern, and muscle biopsy confirmed an inflammatory myopathy. Although steroids were introduced, the clinical course was unsatisfactory; ophthalmic and bulbar symptomatology appeared. The association of myasthenia gravis was confirmed by an elevated level of serum acetylcholine receptor. A chest computed tomography scan had identified a thymoma. Treated with prednisone, pyridostigmine, and thymectomy, the patient’s clinical and biological evolution was favorable. Conclusion This case illustrates an exceptional association of two entities and the difficulty encountered during their diagnosis and treatment. The management of these two diseases is different, so it is essential to recognize this concomitant presentation.
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Affiliation(s)
- Abdelkhaleq Maaroufi
- Department of Internal Medicine B, Mohamed V Military Hospital, Faculty of Medical Sciences, University Mohammed V, Rabat, Morocco.
| | - Naoufal Assoufi
- Department of Internal Medicine B, Mohamed V Military Hospital, Faculty of Medical Sciences, University Mohammed V, Rabat, Morocco
| | - Mohamed Amine Essaoudi
- Department of pathology, Mohamed V Military Hospital, Faculty of Medical Sciences, University Mohammed V, Rabat, Morocco
| | - Jamal Fatihi
- Department of Internal Medicine B, Mohamed V Military Hospital, Faculty of Medical Sciences, University Mohammed V, Rabat, Morocco
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7
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Doherty L, Chaudhry V. Inpatient Diagnosis and Management of Neuromuscular Disorders. Semin Neurol 2021; 41:493-510. [PMID: 34619777 DOI: 10.1055/s-0041-1733794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Although many neuromuscular conditions are evaluated on an outpatient basis owing to their chronic or progressive nature, more urgent evaluation and management is often required for the inpatient presenting with acute to subacute focal or generalized numbness or weakness. This review focuses on clinical pattern recognition and basic anatomic localization principles to aid in the identification of common, as well as some less frequently encountered, neuromuscular disorders in hospitalized patients. The characteristic clinical and diagnostic features, associated complications, and recommended treatments of key neuromuscular conditions with acute and subacute manifestations are discussed. These conditions can be life-threatening in some cases, such as in Guillain-Barré syndrome, owing to associated oropharyngeal weakness, respiratory failure, or marked dysautonomia. Prompt recognition of the clinical and pathologic features is therefore necessary to reduce associated morbidity and mortality.
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Affiliation(s)
- Leana Doherty
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vinay Chaudhry
- Department of Neurology, Division of Neuromuscular Medicine, University of North Carolina School of Medicine Chapel Hill, North Carolina
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8
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Kubo T, Hirohashi Y, Tsukahara T, Kanaseki T, Murata K, Morita R, Torigoe T. Immunopathological basis of immune-related adverse events induced by immune checkpoint blockade therapy. Immunol Med 2021; 45:108-118. [PMID: 34542015 DOI: 10.1080/25785826.2021.1976942] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Despite the considerable success of cancer immunotherapy with immune checkpoint inhibitors, their nonspecific release of the immunosuppressive mechanism is often associated with immune-related adverse events (irAEs). irAEs significantly disturb patients' quality of life and can even be life-threatening. Therefore, the appropriate management of irAEs is crucial for the development of further reliable cancer immunotherapies. irAEs have the appearance of ordinary autoimmune diseases in one aspect but often have distinct features. Although the detailed pathogenesis of irAEs remains unclear, increasing numbers of studies have provided numerous clues. Here, we review the current knowledge on irAEs, particularly from an immunopathological basis.
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Affiliation(s)
- Terufumi Kubo
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Yoshihiko Hirohashi
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Tomohide Tsukahara
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Takayuki Kanaseki
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Kenji Murata
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Rena Morita
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan.,Division of Fundamental Health Sciences, School of Nursing and Social Services, Health Sciences University of Hokkaido, Tobetsu, Japan
| | - Toshihiko Torigoe
- Department of Pathology, School of Medicine, Sapporo Medical University, Sapporo, Japan
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Kanbayashi T, Tanaka S, Hatanaka Y, Uchio N, Shimizu J, Sonoo M. Myasthenia gravis with inflammatory myopathy without elevation of creatine kinase. Neuromuscul Disord 2021; 31:570-573. [PMID: 34016494 DOI: 10.1016/j.nmd.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 12/30/2020] [Accepted: 03/23/2021] [Indexed: 11/17/2022]
Abstract
Cases of myasthenia gravis with inflammatory myopathy usually show elevated creatine kinase (CK) levels. There are few case reports of myasthenia gravis with inflammatory myopathy without elevated CK levels, and clinical features and useful diagnostic methods for these patients are little known. We describe the case of a 79-year-old man with myasthenia gravis that was complicated with inflammatory myopathy without elevated CK levels and successfully treated with immunological treatment. Initially, he was diagnosed with ocular myasthenia gravis and treated with pyridostigmine, but dysphagia and weakness in the neck and bilateral upper limb without fatigability gradually developed. Needle electromyography revealed myopathic changes, and the results of muscle biopsy were consistent with inflammatory myopathy. Blood tests showed normal CK levels throughout the clinical course and elevated myoglobin levels alone. The possibility of developing inflammatory myopathy in patients with myasthenia gravis cannot be excluded, even if CK levels are normal.
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Affiliation(s)
- Takamichi Kanbayashi
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku 1738605, Tokyo, Japan.
| | - Sonoko Tanaka
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku 1738605, Tokyo, Japan
| | - Yuki Hatanaka
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku 1738605, Tokyo, Japan.
| | - Naohiro Uchio
- Department of Neurology, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku 1138655, Tokyo, Japan.
| | - Jun Shimizu
- Department of Neurology, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku 1138655, Tokyo, Japan; Department of Physical Therapy, School of Health Science, Tokyo University of Technology, Nishikamata 5-23-22, Ota-ku 1448535, Tokyo, Japan.
| | - Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku 1738605, Tokyo, Japan.
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Minami H, Doi T, Toyoda M, Imamura Y, Kiyota N, Mitsuma A, Shimokata T, Naito Y, Matsubara N, Tajima T, Tokushige K, Ishihara K, Cameron S, Ando Y. Phase I study of the antiprogrammed cell death-1 Ab spartalizumab (PDR001) in Japanese patients with advanced malignancies. Cancer Sci 2021; 112:725-733. [PMID: 33031626 PMCID: PMC7893979 DOI: 10.1111/cas.14678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 09/22/2020] [Accepted: 09/30/2020] [Indexed: 01/01/2023] Open
Abstract
Spartalizumab is a humanized IgG4/κ mAb directed against human programmed cell death-1 (PD-1). In this phase I study, we investigated safety, pharmacokinetics, preliminary antitumor activity, and toxicity of spartalizumab in patients with advanced malignancies. Patients (n = 18) with a range of tumor types received spartalizumab i.v. at doses of 1, 3, and 10 mg/kg every 2 weeks until disease progression, unacceptable toxicity, or discontinuation at the discretion of the investigator or patient. Most patients (61%) had received five or more prior lines of therapy. No dose-limiting toxicities were reported and, hence, the maximum tolerated dose was 10 mg/kg or more. Pharmacokinetics in Japanese patients aligned with those reported in a global dose-escalation study. The safety profile was consistent with other approved anti-PD-1 mAbs; the most common drug-related adverse events were maculopapular rash (22%), followed by malaise and increased blood alkaline phosphatase (11% each). Partial responses were reported in two patients (11%), one with transitional cell carcinoma and the other with hepatocellular carcinoma. In conclusion, this study confirmed the safety of spartalizumab given at a dose of up to 10 mg/kg every 2 weeks in Japanese patients with cancers.
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Affiliation(s)
- Hironobu Minami
- Kobe University Graduate School of Medicine and HospitalKobeJapan
| | | | - Masanori Toyoda
- Kobe University Graduate School of Medicine and HospitalKobeJapan
| | | | - Naomi Kiyota
- Kobe University Graduate School of Medicine and HospitalKobeJapan
| | | | | | - Yoichi Naito
- National Cancer Center Hospital EastKashiwaJapan
| | | | | | | | | | - Scott Cameron
- Novartis Institutes for BioMedical ResearchCambridgeMAUSA
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11
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Natera‐Villalba E, Corral‐Corral I, Cabañes L, Pian H, Buisán‐Catevilla FJ. Acute concomitant presentation of polymyositis and atypical myasthenia gravis: a diagnostic challenge. Eur J Neurol 2020; 27:e77-e78. [DOI: 10.1111/ene.14263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/07/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | - I. Corral‐Corral
- Neurology Department Ramón y Cajal University Hospital Madrid Spain
| | - L. Cabañes
- Clinical Neurophysiology Department Ramón y Cajal University Hospital Madrid Spain
| | - H. Pian
- Pathological Anatomy Department Ramón y Cajal University Hospital Madrid Spain
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12
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Steven NM, Fisher BA. Management of rheumatic complications of immune checkpoint inhibitor therapy - an oncological perspective. Rheumatology (Oxford) 2020; 58:vii29-vii39. [PMID: 31816079 PMCID: PMC6900910 DOI: 10.1093/rheumatology/kez536] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/30/2019] [Indexed: 02/06/2023] Open
Abstract
Immune checkpoint inhibitors (CPIs) are an effective treatment for many cancers but cause diverse immune-related adverse events (IrAEs). Rheumatological IrAEs include arthralgia, arthritis, tenosynovitis, myositis, polymyalgia rheumatica and sicca syndrome. CPI use can unmask RA as well as causing flares of prior autoimmune or connective tissue disease. Oncologists categorize and grade IrAEs using the Common Terminology Criteria for Adverse Events and manage them according to international guidelines. However, rheumatological events are unfamiliar territory: oncologists need to work with rheumatologists to elicit and assess symptoms, signs, results of imaging and autoantibody testing and to determine the use of steroids and DMARDs. Myositis may overlap with myasthenic crisis and myocarditis and can be life-threatening. Treatment should be offered on balance of risk and benefit, including whether to continue CPI treatment and recognizing the uncertainty over whether glucocorticoids and DMARDs might compromise cancer control.
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Affiliation(s)
- Neil M Steven
- Institute of Immunology and Immunotherapy, Birmingham, UK.,Cancer Centre, University Hospital Birmingham, Birmingham, UK
| | - Benjamin A Fisher
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,National Institute of Health Research Birmingham Biomedical Research Centre and Department of Rheumatology, University Hospital Birmingham, Birmingham, UK
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13
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Dubey D, David WS, Reynolds KL, Chute DF, Clement NF, Cohen JV, Lawrence DP, Mooradian MJ, Sullivan RJ, Guidon AC. Severe Neurological Toxicity of Immune Checkpoint Inhibitors: Growing Spectrum. Ann Neurol 2020; 87:659-669. [PMID: 32086972 DOI: 10.1002/ana.25708] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
Expanding use of immune-checkpoint inhibitors (ICIs) underscores the importance of accurate diagnosis and timely management of neurological immune-related adverse events (irAE-N). We evaluate the real-world frequency, phenotypes, co-occurring immune-related adverse events (irAEs), and long-term outcomes of severe, grade III to V irAE-N at a tertiary care center over 6 years. We analyze how our experience supports published literature and professional society guidelines. We also discuss these data with regard to common clinical scenarios, such as combination therapy, ICI rechallenge and risk of relapse of irAE-N, and corticosteroid taper, which are not specifically addressed by current guidelines and/or have limited data. Recommendations for management and future irAE-N reporting are outlined. ANN NEUROL 2020;87:659-669.
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Affiliation(s)
- Divyanshu Dubey
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Department of Neurology, and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - William S David
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Kerry L Reynolds
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Donald F Chute
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Nathan F Clement
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Justine V Cohen
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | | | | | - Ryan J Sullivan
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Amanda C Guidon
- Department of Neurology, Massachusetts General Hospital, Boston, MA
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14
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Huang G, Zhou X, Yao D. Report of a case of necrotizing autoimmune myopathy with thymoma-associated myasthenia gravis. Int J Neurosci 2020; 130:1178-1181. [PMID: 32075478 DOI: 10.1080/00207454.2020.1730366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: Myasthenia gravis (MG) is an autoimmune disease and closely related to thymoma. Inflammatory myopathy may accompany with other autoimmune diseases. However, concurrence of inflammatory myopathy and MG is very rare. Necrotizing autoimmune myopathy (NAM), a rare form of inflammatory myopathy, is characterized by necrosis and regeneration of myocytes in proximal muscles without significant inflammation. The aim of the study was to report a rare case of NAM and concomitant thymoma-associated MG after thymectomy.Materials and methods/results: A 27-year-old female patient presented with muscle soreness and weakness in four limbs. Eyelid fatigue and neostigmine tests were negative, and no ptosis was found but the electromyographic examination (EMG) showed myogenic damage and a gradual decrease in the amplitude (20%) of EMG activities evoked by repetitive electrical stimulation. Antibodies against AChR and increased titer of creatine kinase were detected and plaque-like signals in both legs were found in magnetic resonance imaging. Myositis-related antibodies were negative but necrotic myocytes without inflammatory cell infiltration, and MHC-1 positive muscle fibers were found in muscle biopsy. Pathological examination confirmed anterior mediastinal B2 type thymoma. Five weeks after thymectomy, she started to show typical MG symptoms. No recurrence of thymoma was found but immunoassay showed a higher titer of AChR-Ab. Myositis-related antibodies negative necrotizing autoimmune myopathy (NAM) was reported to be associated with thymoma-associated MG.Conclusions: The patient showed symptoms related NAM but developed MG-related symptoms only after thymectomy. The mechanisms for the phenomena may be related to immune dysfunction associated with thymoma.
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Affiliation(s)
- Gang Huang
- Neurological Institute of Jiangxi Province and Department of Neurology, Jiangxi Provincial People's Hospital, Nanchang University, Jiangxi, PR China
| | - Xinhua Zhou
- Neurological Institute of Jiangxi Province and Department of Neurology, Jiangxi Provincial People's Hospital, Nanchang University, Jiangxi, PR China
| | - Dongyuan Yao
- Neurological Institute of Jiangxi Province and Department of Neurology, Jiangxi Provincial People's Hospital, Nanchang University, Jiangxi, PR China
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15
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Sureshbabu S, Nikitha K, Bhasi R, Sreevidya LK. A neuro-immunological cocktail. INTERNATIONAL JOURNAL OF ACADEMIC MEDICINE 2020. [DOI: 10.4103/ijam.ijam_32_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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16
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Lambrianides S, Kinnis E, Cleanthous M, Papacharalambous R, Panayiotou E, Zamba-Papanicolaou E, Kyriakides T. A novel case of inclusion body myositis and myasthenia gravis. Neuromuscul Disord 2019; 29:771-775. [DOI: 10.1016/j.nmd.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/30/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022]
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17
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Nicolau S, Kao JC, Liewluck T. Trouble at the junction: When myopathy and myasthenia overlap. Muscle Nerve 2019; 60:648-657. [PMID: 31449669 DOI: 10.1002/mus.26676] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/18/2019] [Accepted: 08/20/2019] [Indexed: 12/22/2022]
Abstract
Although myopathies and neuromuscular junction disorders are typically distinct, their coexistence has been reported in several inherited and acquired conditions. Affected individuals have variable clinical phenotypes but typically display both a decrement on repetitive nerve stimulation and myopathic findings on muscle biopsy. Inherited causes include myopathies related to mutations in BIN1, DES, DNM2, GMPPB, MTM1, or PLEC and congenital myasthenic syndromes due to mutations in ALG2, ALG14, COL13A1, DOK7, DPAGT1, or GFPT1. Additionally, a decrement due to muscle fiber inexcitability is observed in certain myotonic disorders. The identification of a defect of neuromuscular transmission in an inherited myopathy may assist in establishing a molecular diagnosis and in selecting patients who would benefit from pharmacological correction of this defect. Acquired cases meanwhile stem from the co-occurrence of myasthenia gravis or Lambert-Eaton myasthenic syndrome with an immune-mediated myopathy, which may be due to paraneoplastic disorders or exposure to immune checkpoint inhibitors.
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Affiliation(s)
- Stefan Nicolau
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Justin C Kao
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
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18
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Zhou Z, Chen X, Liu G, Pu J, Wu J. Presence of Multiple Autoimmune Antibodies Involved in Concurrent Myositis and Myocarditis and Myasthenia Gravis Without Thymoma: A Case Report. Front Neurol 2019; 10:770. [PMID: 31379720 PMCID: PMC6646736 DOI: 10.3389/fneur.2019.00770] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/02/2019] [Indexed: 11/13/2022] Open
Abstract
Inflammatory myositis (IM) and myasthenia gravis (MG) are both immune disorders involving muscle. The concurrent presence of both conditions in the same patient is extremely rare and the diagnosis is important and challenging. Here, we report a case of concurrent myositis and myocarditis and MG without thymoma in a 69-year-old man with progressive proximal muscle weakness and dysphagia. As an atypical finding, the laboratory immunity assay showed the presence of multiple antibodies (acetylcholine receptor-Ab, titin-Ab, M7-Ab, smooth muscle alpha (SMA)-Ab, and citrate acid extract (CAE)-Ab). We predicted that thymoma-associated antibodies (titin-Ab, SMA-Ab, and CAE-Ab) and anti-M7 antibodies play an important role in the concurrent presence of MG and myositis and myocarditis. In this overlap case, immunotherapy was determined to be effective.
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Affiliation(s)
- Zhijian Zhou
- Department of Neurology, Affiliated Shaoxing Hospital of Traditional Chinese Medicine, Zhejiang Chinese Medical University, Shaoxing, China.,Department of Neurology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xia Chen
- Department of Neurology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Department of Neurology, Shangrao People's Hospital, Shangrao, China
| | - Gonglu Liu
- Department of Neurology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jiali Pu
- Department of Neurology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jimin Wu
- Department of Neurology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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19
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Concurrent inflammatory myopathy and myasthenia gravis with or without thymic pathology: A case series and literature review. Semin Arthritis Rheum 2019; 48:745-751. [DOI: 10.1016/j.semarthrit.2018.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 04/20/2018] [Accepted: 05/14/2018] [Indexed: 11/22/2022]
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20
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Myositis Mimics—a Clinical Approach to a Diagnostic Challenge. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2018. [DOI: 10.1007/s40674-018-0108-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Hamada S, Fuseya Y, Tsukino M. Pembrolizumab-Induced Rhabdomyolysis With Myositis in a Patient With Lung Adenocarcinoma. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.arbr.2018.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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22
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Hamada S, Fuseya Y, Tsukino M. Pembrolizumab-Induced Rhabdomyolysis With Myositis in a Patient With Lung Adenocarcinoma. Arch Bronconeumol 2018; 54:346-348. [DOI: 10.1016/j.arbres.2018.01.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 12/12/2022]
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23
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Mitsumune S, Manabe Y, Yunoki T, Kono S, Aoyama K, Shinno Y, Narai H, Abe K. Autologous Bone Marrow Transplantation for Polymyositis Combined with Myasthenia Gravis and Aplastic Anemia: A Case Report. Case Rep Neurol 2018; 10:108-111. [PMID: 29805377 PMCID: PMC5968255 DOI: 10.1159/000488476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/14/2018] [Indexed: 11/26/2022] Open
Abstract
This is the first report about a patient with concomitant polymyositis (PM), myasthenia gravis (MG), and aplastic anemia (AA). A 54-year-old male developed myalgia and muscle weakness, which gradually progressed over 2 months. He was persistently affected by MG and AA. Brachium magnetic resonance imaging showed increased signal intensity in the left triceps and deltoid muscles on short tau inversion recovery images. A muscle biopsy examination revealed perifascicular atrophication and inflammatory myopathy. We diagnosed the patient with PM combined with MG and AA. He was successfully treated with an autologous bone marrow transplantation (BMT). The present case suggests that BMT is a therapeutic option for PM, MG, and AA.
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Affiliation(s)
- Sho Mitsumune
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yasuhiro Manabe
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Taijun Yunoki
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Shyoichiro Kono
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Kazutoshi Aoyama
- Department of Hematology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yoko Shinno
- Clinical Laboratory, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hisashi Narai
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Koji Abe
- Department of Neurology, Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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24
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Abstract
PURPOSE OF REVIEW This article provides guidelines for diagnosing and treating the different subtypes of autoimmune myopathies. RECENT FINDINGS The most common subtypes of autoimmune myopathies are dermatomyositis, immune-mediated necrotizing myopathy, antisynthetase syndrome, and overlap syndromes; isolated polymyositis is an exceptionally rare disease. Specific autoantibodies are associated with unique clinical phenotypes and may be used for diagnostic and prognostic purposes, such as to assess the risk of coexisting malignancy. SUMMARY Diagnosing the specific subtype of autoimmune myopathy can be achieved by combining relevant features of the history, neuromuscular examination, muscle biopsy, and serologic studies.
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25
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Mayousse V, Jeandel A, Blanchard-Gutton N, Escriou C, Gnirs K, Shelton GD, Blot S. Evaluation of coexisting polymyositis in feline myasthenia gravis: A case series. Neuromuscul Disord 2017; 27:804-815. [PMID: 28687435 DOI: 10.1016/j.nmd.2017.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 06/13/2017] [Accepted: 06/14/2017] [Indexed: 12/27/2022]
Abstract
Acquired myasthenia gravis (MG) is relatively uncommon in cats. In humans, MG may be associated with other immune-mediated disorders, in particular polymyositis (PM). In this study, we described in-depth electrodiagnostic findings and pathological changes in muscles of cats diagnosed with MG, and assessed the presence of concurrent PM. Six cats with confirmed acetylcholine receptor antibody seropositive MG, and two suspected cases with clinical signs and electrophysiological changes consistent with MG, were reviewed. All animals presented with severe typical signs of generalized weakness and/or fatigability, resembling late-onset MG in humans, in addition to regurgitation. Five cats presented a cranial mediastinal mass, with 3 confirmed as thymoma. Repetitive nerve stimulation revealed a decrement of the compound muscle action potential in all tested cases, starting from low frequencies of stimulation. Serum creatine kinase activity was increased in 6/8 cats. Muscle biopsies performed in 5 cats revealed varying degrees of mixed mononuclear cell infiltrates, positive for the leukocyte markers CD3/CD4/CD8 and CD11b. Further MHC-1/C5b-9 positive sarcolemmal deposits were identified in all tested cases, with or without thymoma. This study documents an association of MG and PM in cats, and provides further support for feline MG as a relevant animal model of human MG.
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Affiliation(s)
- Vincent Mayousse
- Université Paris-Est, Ecole nationale vétérinaire d'Alfort (EnvA), Unité de Neurologie, 7 avenue du Général de Gaulle, 94700 Maisons-Alfort, France; Inserm, IMRB U955-E10 Biology of the Neuromuscular System, 8 rue du général Sarrail, 94000 Créteil, France.
| | - Aurélien Jeandel
- Université Paris-Est, Ecole nationale vétérinaire d'Alfort (EnvA), Unité de Neurologie, 7 avenue du Général de Gaulle, 94700 Maisons-Alfort, France
| | - Nicolas Blanchard-Gutton
- Inserm, IMRB U955-E10 Biology of the Neuromuscular System, 8 rue du général Sarrail, 94000 Créteil, France
| | - Catherine Escriou
- Unité de Neurologie, VetAgro-Sup, Campus Veterinaire de Lyon, 1 Avenue Bourgelat, 69280 Marcy l'Etoile, France
| | - Kirsten Gnirs
- Clinique Advetia, 5 rue Dubrunfaut, 75012 Paris, France
| | - G Diane Shelton
- Department of Pathology, School of Medicine, University of California San Diego, La Jolla, CA 92093-0709, USA
| | - Stéphane Blot
- Université Paris-Est, Ecole nationale vétérinaire d'Alfort (EnvA), Unité de Neurologie, 7 avenue du Général de Gaulle, 94700 Maisons-Alfort, France; Inserm, IMRB U955-E10 Biology of the Neuromuscular System, 8 rue du général Sarrail, 94000 Créteil, France
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26
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Kannaditharayil D, Napier F, Granit V, Bieri P, Herskovitz S. Abnormal spontaneous activity on needle electromyography in myasthenia gravis. Muscle Nerve 2017; 56:E11-E12. [PMID: 28214328 DOI: 10.1002/mus.25615] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 02/08/2017] [Accepted: 02/14/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Deepa Kannaditharayil
- EMG Laboratory; Montefiore Medical Center; 111 East 210th Street Bronx New York 10467 USA
| | - Fabreena Napier
- EMG Laboratory; Montefiore Medical Center; 111 East 210th Street Bronx New York 10467 USA
| | - Volkan Granit
- EMG Laboratory; Montefiore Medical Center; 111 East 210th Street Bronx New York 10467 USA
| | - Phyllis Bieri
- EMG Laboratory; Montefiore Medical Center; 111 East 210th Street Bronx New York 10467 USA
| | - Steven Herskovitz
- EMG Laboratory; Montefiore Medical Center; 111 East 210th Street Bronx New York 10467 USA
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27
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Gonzalez NL, Puwanant A, Lu A, Marks SM, Živković SA. Myasthenia triggered by immune checkpoint inhibitors: New case and literature review. Neuromuscul Disord 2017; 27:266-268. [PMID: 28109638 DOI: 10.1016/j.nmd.2017.01.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/05/2017] [Indexed: 01/13/2023]
Abstract
Immune checkpoint molecules are potent regulators of immunologic homeostasis that prevent the development of autoimmunity while maintaining self-tolerance. Inhibitors of immune checkpoint molecules are used as immunotherapy in the treatment of melanoma and different types of refractory cancer, and can trigger various autoimmune complications including myositis and myasthenia gravis. We describe a case of generalized myasthenia gravis induced by pembrolizumab and review 11 other cases. Five patients also had elevated serum CK levels ranging from 1200 to 8729 IU/L, and biopsy showed myositis in one. Severity was highly variable as symptoms normalized spontaneously in one patient, but three others developed myasthenic crisis (including two with fatal outcomes). Steroids have been recommended as a preferred treatment of autoimmune complications of immune-checkpoint inhibitors. Myasthenia gravis should be considered when weakness, diplopia or bulbar symptoms are seen after treatment with immune checkpoint inhibitors, and additional studies are needed to characterize association with hyperCKemia.
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Affiliation(s)
- Natalia L Gonzalez
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Araya Puwanant
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Angela Lu
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Stanley M Marks
- Pittsburgh Cancer Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
| | - Saša A Živković
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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28
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Ishiguro T, Kagiyama N, Kawate E, Odashima K, Takaku Y, Kurashima K, Takayanagi N. Development of myasthenia gravis 8 years after interstitial lung disease associated with antisynthetase (anti-EJ antibody) syndrome. Clin Case Rep 2016; 5:61-65. [PMID: 28096992 PMCID: PMC5224770 DOI: 10.1002/ccr3.747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 09/06/2016] [Accepted: 10/18/2016] [Indexed: 11/08/2022] Open
Abstract
Patients with antisynthetase-positive interstitial lung disease (ILD) alone sometimes develop myositis during follow-up, but myasthenia gravis (MG) overlapping on antisynthetase syndrome is unusual. A 56-year-old woman with ILD and anti-EJ antibody treated for 8 years developed MG. Physicians should consider myositis and MG when patients develop muscle symptoms during follow-up.
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Affiliation(s)
- Takashi Ishiguro
- Department of Respiratory Medicine Saitama Cardiovascular and Respiratory Center Kumagaya Saitama Prefecture Japan
| | - Naho Kagiyama
- Department of Respiratory Medicine Saitama Cardiovascular and Respiratory Center Kumagaya Saitama Prefecture Japan
| | - Eriko Kawate
- Department of Respiratory Medicine Saitama Cardiovascular and Respiratory Center Kumagaya Saitama Prefecture Japan
| | - Kyuto Odashima
- Department of Respiratory Medicine Saitama Cardiovascular and Respiratory Center Kumagaya Saitama Prefecture Japan
| | - Yotaro Takaku
- Department of Respiratory Medicine Saitama Cardiovascular and Respiratory Center Kumagaya Saitama Prefecture Japan
| | - Kazuyoshi Kurashima
- Department of Respiratory Medicine Saitama Cardiovascular and Respiratory Center Kumagaya Saitama Prefecture Japan
| | - Noboru Takayanagi
- Department of Respiratory Medicine Saitama Cardiovascular and Respiratory Center Kumagaya Saitama Prefecture Japan
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29
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Stefanou MI, Komorowski L, Kade S, Bornemann A, Ziemann U, Synofzik M. A case of late-onset, thymoma-associated myasthenia gravis with ryanodine receptor and titin antibodies and concomitant granulomatous myositis. BMC Neurol 2016; 16:172. [PMID: 27623618 PMCID: PMC5022226 DOI: 10.1186/s12883-016-0697-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/07/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myasthenia gravis is an autoimmune neuromuscular disorder, which has only rarely been reported to co-manifest with myositis. The diagnosis of concomitant myositis in patients with myasthenia gravis is clinically challenging, and requires targeted investigations for the differential diagnosis, including EMG, autoantibody assays, muscle biopsy and, importantly, imaging of the mediastinum for thymoma screening. CASE PRESENTATION This report presents a case-vignette of a 72-year-old woman with progressive proximal muscle weakness and myalgias, diagnosed with thymoma-associated myasthenia and bioptically verified granulomatous myositis, with positive autoantibody status for ryanodine receptor and titin antibodies. CONCLUSIONS The diagnosis of concurrent myositis and myasthenia gravis, especially in the presence of ryanodine receptor and titin antibodies, should lead neurologists to adopt different treatment strategies compared to those applied in myasthenia or myositis alone. Moreover, further evidence is warranted that titin and, particularly, ryanodine receptor antibodies may co-occur or be pathophysiologically involved in myasthenia-myositis cases.
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Affiliation(s)
- M I Stefanou
- Department of Neurovascular Diseases, Hertie Institute for Clinical Brain Research & Center for Neurology, Tuebingen, Germany.
| | - L Komorowski
- Institute for Experimental Immunology, Affiliated to Euroimmun AG, Luebeck, Germany
| | - S Kade
- Institute for Experimental Immunology, Affiliated to Euroimmun AG, Luebeck, Germany
| | - A Bornemann
- Department of Neuropathology, University of Tuebingen, Tuebingen, Germany
| | - U Ziemann
- Department of Neurovascular Diseases, Hertie Institute for Clinical Brain Research & Center for Neurology, Tuebingen, Germany
| | - M Synofzik
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research & Center for Neurology, Tuebingen, Germany.,Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Tuebingen, Germany
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30
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Kisabay A, Sari US, Boyaci R, Batum M, Yilmaz H, Selcuki D. Association of myasthenia gravis and Behçet's disease: A case report. Neurol Neurochir Pol 2016; 50:284-7. [DOI: 10.1016/j.pjnns.2016.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 03/13/2016] [Accepted: 03/21/2016] [Indexed: 10/22/2022]
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31
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Simultaneous Combined Myositis, Inflammatory Polyneuropathy, and Overlap Myasthenic Syndrome. Case Rep Neurol Med 2016; 2016:6108234. [PMID: 28044116 PMCID: PMC5156794 DOI: 10.1155/2016/6108234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 10/16/2016] [Indexed: 11/18/2022] Open
Abstract
Immune-mediated neuromuscular disorders include pathologies of the peripheral nervous system, neuromuscular junction, and muscles. If overlap syndromes (or the association of almost two autoimmune disorders) are recognized, the simultaneous occurrence of several autoimmune neuromuscular disorders is rare. We describe two patients presenting the simultaneous occurrence of inflammatory neuropathy, myositis, and myasthenia gravis (with positive acetylcholine receptor antibodies). For each patient, we carried out a pathological analysis (nerve and muscle) and an electrophysiological study (and follow-up). To our knowledge, this is the first description of such a triple immune-mediated neuromuscular syndrome. We compared our observations with a few other cases of simultaneous diagnosis of two inflammatory neuromuscular disorders.
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33
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Sangüesa Gómez C, Flores Robles BJ, Méndez Perles C, Barbadillo C, Godoy H, Andréu JL. Dermatomiositis y miastenia gravis: una asociación infrecuente con implicaciones terapéuticas. ACTA ACUST UNITED AC 2015; 11:244-6. [DOI: 10.1016/j.reuma.2014.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 10/02/2014] [Accepted: 10/10/2014] [Indexed: 12/29/2022]
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34
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Gilhus NE, Nacu A, Andersen JB, Owe JF. Myasthenia gravis and risks for comorbidity. Eur J Neurol 2014; 22:17-23. [PMID: 25354676 DOI: 10.1111/ene.12599] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 09/19/2014] [Indexed: 01/21/2023]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder leading to skeletal muscle weakness and fatigability. MG subgroups are defined according to pathogenetic autoantibody (against acetylcholine receptor, muscle-specific tyrosine kinase or lipoprotein receptor-related protein 4), thymus pathology and clinical manifestations. MG patients have an increased risk for concordant autoimmune disease, in particular with early onset MG. Most common comorbidities are thyroid disease, systemic lupus erythematosus and rheumatoid arthritis. Cardiomyositis and subclinical heart dysfunction have been described in patients with thymoma MG and late onset MG but represent no major threat. A thymic lymphoepithelioma implies an increased risk for another cancer. Autoimmune MG represents no distinct cancer risk factor, although lymphomas and a few other cancer types have been reported with slightly increased frequency. Severe MG-related muscle weakness means a risk for respiratory failure and respiratory tract infection. Drug MG treatment can lead to side-effects. Thymectomy is regarded as a safe procedure both short and long term. Non-MG-related comorbidity represents a diagnostic and therapeutic challenge, especially in elderly patients. Diagnostic accuracy and optimal follow-up is necessary to identify and treat all types of coexisting disease in MG.
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Affiliation(s)
- N E Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Neurology, Haukeland University Hospital, Bergen, Norway
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35
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Cortactin: A new target in autoimmune myositis and Myasthenia Gravis. Autoimmun Rev 2014; 13:1001-2. [DOI: 10.1016/j.autrev.2014.08.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 07/05/2014] [Indexed: 01/21/2023]
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