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Wiendl H, Abicht A, Chan A, Della Marina A, Hagenacker T, Hekmat K, Hoffmann S, Hoffmann HS, Jander S, Keller C, Marx A, Melms A, Melzer N, Müller-Felber W, Pawlitzki M, Rückert JC, Schneider-Gold C, Schoser B, Schreiner B, Schroeter M, Schubert B, Sieb JP, Zimprich F, Meisel A. Guideline for the management of myasthenic syndromes. Ther Adv Neurol Disord 2023; 16:17562864231213240. [PMID: 38152089 PMCID: PMC10752078 DOI: 10.1177/17562864231213240] [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: 05/26/2023] [Accepted: 10/23/2023] [Indexed: 12/29/2023] Open
Abstract
Myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS), and congenital myasthenic syndromes (CMS) represent an etiologically heterogeneous group of (very) rare chronic diseases. MG and LEMS have an autoimmune-mediated etiology, while CMS are genetic disorders. A (strain dependent) muscle weakness due to neuromuscular transmission disorder is a common feature. Generalized MG requires increasingly differentiated therapeutic strategies that consider the enormous therapeutic developments of recent years. To include the newest therapy recommendations, a comprehensive update of the available German-language guideline 'Diagnostics and therapy of myasthenic syndromes' has been published by the German Neurological society with the aid of an interdisciplinary expert panel. This paper is an adapted translation of the updated and partly newly developed treatment guideline. It defines the rapid achievement of complete disease control in myasthenic patients as a central treatment goal. The use of standard therapies, as well as modern immunotherapeutics, is subject to a staged regimen that takes into account autoantibody status and disease activity. With the advent of modern, fast-acting immunomodulators, disease activity assessment has become pivotal and requires evaluation of the clinical course, including severity and required therapies. Applying MG-specific scores and classifications such as Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, and Myasthenia Gravis Foundation of America allows differentiation between mild/moderate and (highly) active (including refractory) disease. Therapy decisions must consider age, thymic pathology, antibody status, and disease activity. Glucocorticosteroids and the classical immunosuppressants (primarily azathioprine) are the basic immunotherapeutics to treat mild/moderate to (highly) active generalized MG/young MG and ocular MG. Thymectomy is indicated as a treatment for thymoma-associated MG and generalized MG with acetylcholine receptor antibody (AChR-Ab)-positive status. In (highly) active generalized MG, complement inhibitors (currently eculizumab and ravulizumab) or neonatal Fc receptor modulators (currently efgartigimod) are recommended for AChR-Ab-positive status and rituximab for muscle-specific receptor tyrosine kinase (MuSK)-Ab-positive status. Specific treatment for myasthenic crises requires plasmapheresis, immunoadsorption, or IVIG. Specific aspects of ocular, juvenile, and congenital myasthenia are highlighted. The guideline will be further developed based on new study results for other immunomodulators and biomarkers that aid the accurate measurement of disease activity.
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Affiliation(s)
- Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, Münster 48149, Germany
| | - Angela Abicht
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Andrew Chan
- Universitätsklinik für Neurologie, Inselspital Bern, Bern, Switzerland
| | - Adela Della Marina
- Klinik für Kinderheilkunde I, Universitätsklinikum Essen, Essen, Germany
| | - Tim Hagenacker
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | | | - Sarah Hoffmann
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
| | | | - Sebastian Jander
- Klinik für Neurologie, Marien Hospital Düsseldorf, Düsseldorf, Germany
| | - Christian Keller
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Alexander Marx
- Pathologisches Institut, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Arthur Melms
- Facharztpraxis für Neurologie und Psychiatrie, Stuttgart, Germany
| | - Nico Melzer
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Wolfgang Müller-Felber
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU Munich, Munich, Germany
| | - Marc Pawlitzki
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | | | - Benedikt Schoser
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Bettina Schreiner
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Switzerland
| | - Michael Schroeter
- Klinik und Poliklinik für Neurologie, Uniklinik Cologne, Cologne, Germany
| | | | | | - Fritz Zimprich
- Universitätsklinik für Neurologie, AKH-Wien, Wien, Austria
| | - Andreas Meisel
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
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Zhen L, Zhao X, Li W, Wu J, Shang H, Chen S, Zhu X, Wang Y, Yu X, Hu G, Sun Z, Zhang Y, Zhang J, Fang H, Zhang Y, Zhang Q, Cui X, Lv J, Yang J, Gao F. Effectiveness of early glucocorticoids in myasthenia gravis: a retrospective cohort study. Front Neurol 2023; 14:1259484. [PMID: 38187148 PMCID: PMC10770254 DOI: 10.3389/fneur.2023.1259484] [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: 07/16/2023] [Accepted: 11/23/2023] [Indexed: 01/09/2024] Open
Abstract
Purpose This study aimed to clarify the effect of early glucocorticoid (GC) application on achieving minimal manifestation (MM) status or better in the treatment of myasthenia gravis (MG) in the early clinical phase. Methods A retrospective analysis was performed using data from 336 patients with MG who received GC therapy from January 2015 to September 2022 in the Zhengzhou University Henan Institute of Medical and Pharmaceutical Sciences Myasthenia Gravis Biobank (ZMB). Patients were divided into two groups: the early mono-GC group (treated with GC within 6 months of MG onset) and the delayed mono-GC group. Results Kaplan-Meier analysis showed that the early mono-GC group achieved MM status earlier and more frequently than the delayed mono-GC group (log-rank test, p = 0.0082; hazard ratio [HR], 1.66; p = 0.011). The early mono-GC group had a lower maintenance oral GC dose than the delayed mono-GC group. In multivariate Cox regression analysis, early mono-GC (HR, 1.50; p = 0.043), early-onset MG (EOMG) (HR, 1.74; p = 0.034), and ocular MG (OMG) (HR, 1.90; p = 0.007) were associated with MM status or better. In conclusion, early mono-GC, EOMG, and OMG were positive predictors of treatment goals. In EOMG, OMG, and acetylcholine receptor antibody-positive MG (AChR-MG) subgroups, the maintenance oral GC doses in the early mono-GC group were significantly lower than the doses in the delayed mono-GC group (p < 0.05). Conclusion Early intervention with GC led to better long-term outcomes and reduced the necessary maintenance dose of oral GC for patients with MG. EOMG and OMG were positive predictors of MM status or better with mono-GC.
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Affiliation(s)
- Lulu Zhen
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Xue Zhao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Wenbo Li
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jinru Wu
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- Basic Medical College, Zhengzhou University, Zhengzhou, China
| | - Haodong Shang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Shufan Chen
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Xiaoyan Zhu
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Yiren Wang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- Basic Medical College, Zhengzhou University, Zhengzhou, China
| | - Xiaoxiao Yu
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Guanlian Hu
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Zhan Sun
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
- BGI College, Zhengzhou University, Zhengzhou, China
| | - Yingna Zhang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jing Zhang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Hua Fang
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Yunke Zhang
- Department of Encephalopathy, First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China
| | - Qingyong Zhang
- Myasthenia Gravis Comprehensive Diagnosis and Treatment Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Xinzheng Cui
- Myasthenia Gravis Comprehensive Diagnosis and Treatment Center, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Jie Lv
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Junhong Yang
- Department of Encephalopathy, First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
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Wilson L, Davis H. The Role of Thymoma and Thymic Hyperplasia as Prognostic Risk Factors for Secondary Generalisation in Adults with Ocular Myasthenia Gravis: A Systematic Narrative Review. Br Ir Orthopt J 2023; 19:108-119. [PMID: 38046270 PMCID: PMC10691285 DOI: 10.22599/bioj.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/06/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose The conversion of ocular myasthenia gravis (OMG) to generalised myasthenia gravis (GMG) is reported to differ depending on the presence of generalisation risk factors (Mazzoli et al. 2018). Thymic pathology has been recognised as a potential risk factor for generalisation in the literature (Teo et al. 2017). Thymoma and thymic hyperplasia have yet to be examined as a risk factor for generalisation of OMG independently of other risk factors in the literature. Thus, the purpose of this review is to examine the literature to identify whether thymoma and thymic hyperplasia do increase the risk of OMG progressing to GMG. Methods A literature search was carried out which employed a systematic approach. The search was undertaken using the following academic libraries: MEDLINE, Embase and Starplus. The search was limited to publications between the years 2001 to 2021. The search yielded 82 studies, which after the screening of titles and abstracts, left 62 studies for further analysis against the inclusion and exclusion criteria. Results The review found thymoma to be associated with an increased risk of GMG development. However, there was a scarce amount of literature which investigated thymic hyperplasia. Therefore, a firm conclusion could not be made with regards to thymic hyperplasia and the risk of GMG development. Conclusions This review provides evidence for the consideration of thymectomy early after thymomatous OMG diagnosis to prevent GMG conversion. As the review did not collect enough evidence to support the influence of thymic hyperplasia on OMG conversion, further research is required.
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Affiliation(s)
| | - Helen Davis
- The medical school University of Sheffield, UK
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Almodovar JL, Mehrabyan A. Disease-Based Prognostication: Myasthenia Gravis. Semin Neurol 2023; 43:799-806. [PMID: 37751854 DOI: 10.1055/s-0043-1775791] [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: 09/28/2023]
Abstract
Myasthenia gravis (MG) is an acquired autoimmune neuromuscular junction transmission disorder that clinically presents as fluctuating or persistent weakness in various skeletal muscle groups. Neuroprognostication in MG begins with some basic observations on the natural history of the disease and known treatment outcomes. Our objective is to provide a framework that can assist a clinician who encounters the MG patient for the first time and attempts to prognosticate probable outcomes in individual patients. In this review article, we explore clinical type, age of onset, antibody status, severity of disease, thymus pathology, autoimmune, and other comorbidities as prognostic factors in MG.
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Affiliation(s)
- Jorge L Almodovar
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anahit Mehrabyan
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Narita T, Nakane S, Nagaishi A, Minami N, Niino M, Kawaguchi N, Murai H, Kira JI, Shimizu J, Iwasa K, Yoshikawa H, Hatanaka Y, Sonoo M, Shimizu Y, Matsuo H. Immunotherapy for ocular myasthenia gravis: an observational study in Japan. Ther Adv Neurol Disord 2023; 16:17562864231163819. [PMID: 37051222 PMCID: PMC10084546 DOI: 10.1177/17562864231163819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/27/2023] [Indexed: 04/14/2023] Open
Abstract
Background Treatment for ocular myasthenia gravis (OMG) has not yet been well established. Few reports have been published on the clinical practice and outcomes of OMG. Objectives We investigated treatment of OMG and its outcomes in Japan.We investigated treatment of OMG and its outcomes in Japan. Design We performed a retrospective cross-sectional survey of OMG patients from eight hospitals in Japan. Methods Clinical information, including sex, age at onset, initial symptoms, autoantibodies, clinical course, treatment history, complications, and outcomes, was obtained. In addition, we recorded the total number of patients with MG and OMG separately. Results In total, 135 patients with OMG (67 men, 68 women) were included. Treatment of OMG was not simple and involved various immunotherapeutic strategies. Eight patients went into remission spontaneously without immunotherapy. A total of 117 patients showed improvements after treatment, whereas 10 patients showed refractory responses to treatment. Overall outcomes were good; however, symptoms persisted in 60.7% of patients even after treatment. Among 90 patients who received immunotherapy, only two showed a refractory response. Meanwhile, for 45 patients who did not receive immunotherapy, 8 were refractory. Thus, the rate of refractory disease in the group with immunotherapy was significantly lower (p = 0.001, u-test) than in the group without immunotherapy. The proportion of generalized MG patients among all MG cases was low in medical centers where immunotherapy for OMG was frequently performed. Conclusion Although the overall prognosis for patients with OMG was good, symptoms remained in more than half of the patients. Immunotherapy, including corticosteroids, may be beneficial for patients with OMG. Plain language summary Is immunosuppressive therapy beneficial for myasthenia gravis patients with ocular symptoms only? Patients with ocular myasthenia gravis (OMG) have only eye symptoms for more than 2 years. Whether this condition is an initial stage of the disease before eventually progressing to generalized myasthenia gravis (gMG) is still uncertain. Different from gMG, OMG is not life-threatening. But eye symptoms often cause troublesome problems in life. Doctors have treated OMG patients similarly to patients with gMG. There is no standard clinical practice for OMG. In this study, we examined how patients with OMG were treated at eight different specialist centers in Japan. In 135 patients with OMG, 8 patients became symptom free without treatment, 117 patients showed improvements after treatment, whereas 10 patients did not get well. Overall outcomes were good, but symptoms remained in 60.7% of patients even after treatment. Among 90 patients who received one or more immunotherapies, only 2 did not get well. Meanwhile, for 45 patients who did not receive immunotherapy, 8 remained ill. We found that treatment of OMG was not simple and often needed multiple immunotherapies. Administering immunotherapy, including corticosteroids, may be beneficial for patients with OMG.
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Affiliation(s)
| | | | - Akiko Nagaishi
- Department of Neurology, National Hospital Organization, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization, Hokkaido Medical Center, Sapporo, Japan
| | - Masaaki Niino
- Department of Neurology, National Hospital Organization, Hokkaido Medical Center, Sapporo, Japan
| | | | - Hiroyuki Murai
- Department of Neurology, Neurological Institute, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
- Department of Neurology, International University of Health and Welfare, Tokyo, Japan
| | - Jun-ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Jun Shimizu
- Department of Neurology, Tokyo University, Tokyo, Japan
| | - Kazuo Iwasa
- Department of Neurology and Neurobiology of Aging, Kanazawa University, Kanazawa, Japan
| | - Hiroaki Yoshikawa
- Department of Neurology and Neurobiology of Aging, Kanazawa University, Kanazawa, Japan
- Health Service Center, Kanazawa University, Kanazawa, Japan
| | - Yuki Hatanaka
- Department of Neurology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Masahiro Sonoo
- Department of Neurology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Yuko Shimizu
- Department of Neurology, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
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Point Counter-Point: Thymectomy in Ocular Myasthenia Gravis. J Neuroophthalmol 2022; 42:541-546. [PMID: 36394968 DOI: 10.1097/wno.0000000000001748] [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]
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Generalization of ocular myasthenia gravis 10 years after onset. J Neurol 2022; 269:6597-6604. [PMID: 36001142 DOI: 10.1007/s00415-022-11316-3] [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: 05/19/2022] [Revised: 07/24/2022] [Accepted: 07/28/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Generalization of ocular myasthenia gravis (OMG) represents a pejorative evolution, and no validated generalization-prevention strategy exists. The study aimed to determine the percentage of patients with OMG generalization and identify factors predictive of it to establish a prediction score. METHODS This retrospective, observational study included 151 patients diagnosed with OMG after an initial work-up in our institution. The outcome measure was time to MG generalization. The explanatory variables were age at onset (> 55 years), sex, first-year anti-acetylcholine-receptor antibody-positivity, repetitive nerve stimulation showing electromyogram decrement and corticosteroid use. Kaplan-Meier estimations of the probability of risk of generalization, and descriptive and multivariate Cox model analyses were computed. A nomogram combining explanatory variables was used to establish a score to predict the probability of OMG generalization. RESULTS Among 183 patients' charts identified, 151 had confirmed OMG. Their median follow-up was 5.7 years. Estimations (95% CI) of OMG-generalization risk at 1, 3 and 10 years post-symptom onset, respectively, were: 13.0% (7.3-18.2), 25.1% (17.5-32.0) and 37.8% (27.2-45.2). The p-value-based multivariate analysis associated generalization with female sex, electromyogram decrement and first-year anti-acetylcholine-receptor antibody positivity, and Akaike information criterion-based analysis retained those three parameters and corticosteroid use. A nomogram was built and validated with an optimism-corrected C-statistic of 0.68, and calibration plots showed good fit. CONCLUSIONS Our population's percentage of OMG generalization is in line with recent publications. Using the identified prognostic factors, the nomogram provided a score to predict the probable risk of generalization in our cohort.
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Ruan Z, Sun C, Lang Y, Gao F, Guo R, Xu Q, Yu L, Wu S, Lei T, Liu Y, Zhang M, Li H, Tang Y, Gao T, Gao Y, Lu X, Li Z, Chang T. Development and Validation of a Nomogram for Predicting Generalization in Patients With Ocular Myasthenia Gravis. Front Immunol 2022; 13:895007. [PMID: 35874731 PMCID: PMC9302474 DOI: 10.3389/fimmu.2022.895007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/08/2022] [Indexed: 11/14/2022] Open
Abstract
Background This study aims to develop and validate a nomogram for predicting 1- and 2-year generalization probabilities in patients with ocular myasthenia gravis (OMG). Methods In total, 501 eligible patients with OMG treated at seven tertiary hospitals in China between January 2015 and May 2019 were included. The primary outcome measure was disease generalization. A nomogram for predicting 1- and 2-year generalization probabilities was constructed using a stepwise Cox regression model. Nomogram performance was quantified using C-indexes and calibration curves. Two-year cumulative generalization rates were analyzed using the Kaplan−Meier method for distinct nomogram-stratified risk groups. The clinical usefulness of the nomogram was evaluated using decision curve analysis (DCA). Result The eligible patients were randomly divided into a development cohort (n=351, 70%) and a validation cohort (n=150, 30%). The final model included five variables: sex, onset age, repetitive nerve stimulation findings, acetylcholine receptor antibody test results, and thymic status. The model demonstrated good discrimination (C-indexes of 0.733 and 0.788 in the development and validation cohorts, respectively) and calibration, with good agreement between actual and nomogram-estimated generalization probabilities. Kaplan−Meier curves revealed higher 2-year cumulative generalization rates in the high-risk group than that in the low-risk group. DCA demonstrated a higher net benefit of nomogram-assisted decisions compared to treatment of all patients or none. Conclusion The nomogram model can predict 1- and 2-year generalization probabilities in patients with OMG and stratified these patients into distinct generalization risk groups. The nomogram has potential to aid neurologists in selecting suitable patients for initiating immunotherapy and for enrolment in clinical trials of risk-modifying treatments.
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Affiliation(s)
- Zhe Ruan
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Chao Sun
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Yanlin Lang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Rongjing Guo
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Quan Xu
- Department of Thoracic Surgery, Jiangxi Provincial People’s Hospital Affiliated to Nanchang University, Nanchang, China
| | - Liping Yu
- Department of Neurology, Xianyang First People’s Hospital, Xianyang, China
| | - Songdi Wu
- Department of Neurology, Xi'an No.1 Hospital, Xi’an, China
| | - Tao Lei
- Department of Neurology, Xi’an Fourth People’s Hospital, Xi’an, China
| | - Yu Liu
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Min Zhang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Huanhuan Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Yonglan Tang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Ting Gao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Yanwu Gao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Xiaodan Lu
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
- *Correspondence: Zhuyi Li, ; Ting Chang,
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi’an, China
- *Correspondence: Zhuyi Li, ; Ting Chang,
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Ocular myasthenia gravis and risk factors for developing a secondary generalisation: description of a Spanish series. NEUROLOGÍA (ENGLISH EDITION) 2022; 38:229-235. [PMID: 35637136 DOI: 10.1016/j.nrleng.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/08/2020] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Ocular myasthenia gravis (MG) is the most common phenotype of MG at onset. A variable percentage of these patients develop secondary generalisation; the risk factors for conversion and the protective effect of immunosuppressive treatment are currently controversial. PATIENTS AND METHODS We designed a retrospective single-centre study with the aim of describing the demographic, clinical, and laboratory characteristics of a Spanish cohort of patients with ocular MG from Hospital Universitario de Albacete from January 2008 to February 2020. RESULTS We selected 62 patients with ocular MG from a cohort of 91 patients with MG (68.1%). Median age at diagnosis was 68 (IQR, 52-75.3), and men accounted for 61.3% of the sample (n = 38). Most patients presented very late-onset ocular MG (n = 34, 54.8%). Binocular diplopia was the most frequent initial symptom (51.7%). The rate of progression to generalised MG was 50% (n = 31), with a median time of 6 months (IQR, 2-12.8). Female sex (OR: 5.46; 95% CI, 1.16-25-74; P= .03) and anti-acetylcholine receptor antibodies (OR: 8.86; 95% CI, 1.15-68.41; P = .04) were significantly associated with the risk of developing generalised MG. CONCLUSIONS The conversion rate observed in our series is relatively high. Generalisation of MG mainly occurs during the first 2 years of progression, and is strongly associated with female sex and especially with the presence of anti-acetylcholine receptor antibodies.
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Risk for generalization in ocular onset myasthenia gravis: experience from a neuro-ophthalmology clinic. Acta Neurol Belg 2022; 122:337-344. [PMID: 33544334 DOI: 10.1007/s13760-020-01582-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/17/2020] [Indexed: 01/13/2023]
Abstract
Conversion to generalized myasthenia gravis (GMG) within the first 2 years has been reported in 18-85% of patients with ocular myasthenia gravis (OMG). The aim of the study was to investigate the risk factors for generalization in patients with OMG admitted to a neuro-ophthalmology clinic and to determine if there were differences between patients with GMG with predominant bulbar (GMG-B) or extremity muscle (GMG-E) involvement according to the 6th and 24th-month Myasthenia Gravis Foundation of America classification ranks. Patients with OMG who were followed-up for at least 24 months were retrospectively analyzed. Demographic, clinical, laboratory features and treatment strategies that can be associated with generalization and time to generalization were evaluated. Of the 139 patients with OMG, 54 (39%) showed generalization with a mean time of 10.3 (range 2-24) months. GMG-B and GMG-E were diagnosed in 31 (22.3%) and 23 patients (16.5%), respectively. Seropositivity for acetylcholine receptor and muscle-specific tyrosine kinase antibodies, abnormal single-fiber electromyography (SFEMG), and the presence of thymic abnormalities (thymoma and hyperplasia) were factors associated with generalization on multivariate analysis without a significant difference between the GMG-B and GMG-E groups. In addition, an abnormal repetitive nerve stimulation test was related to a shortened time to generalization. Bilateral ptosis at onset was found as a risk factor for generalization. In a neuro-ophthalmology clinic, bilateral ptosis as an initial feature of OMG must be approached cautiously because it may be the first sign of impending GMG.
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Alhaidar MK, Abumurad S, Soliven B, Rezania K. Current Treatment of Myasthenia Gravis. J Clin Med 2022; 11:jcm11061597. [PMID: 35329925 PMCID: PMC8950430 DOI: 10.3390/jcm11061597] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/04/2023] Open
Abstract
Myasthenia gravis (MG) is the most extensively studied antibody-mediated disease in humans. Substantial progress has been made in the treatment of MG in the last century, resulting in a change of its natural course from a disease with poor prognosis with a high mortality rate in the early 20th century to a treatable condition with a large proportion of patients attaining very good disease control. This review summarizes the current treatment options for MG, including non-immunosuppressive and immunosuppressive treatments, as well as thymectomy and targeted immunomodulatory drugs.
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Ruan Z, Guo R, Zhou H, Gao F, Lin Y, Xu Q, Yu L, Wu S, Lei T, Zhang M, Gao Y, Lu X, Li H, Sun C, Tang B, Li Z, Chang T. Association of immunosuppression treatment with generalization among patients with ocular myasthenia gravis: a propensity score analysis. Eur J Neurol 2022; 29:1805-1814. [PMID: 35188698 DOI: 10.1111/ene.15292] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/16/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND To analyze disease generalization in patients with ocular myasthenia gravis (OMG) treated with immunosuppression compared with patients without immunosuppression treatment. METHODS In this retrospective cohort study, we analyzed data from patients with OMG at seven medical centers in China from January 1, 2015 to May 1, 2019 and compared disease generalization in patients (treated with immunosuppression vs. not treated) within 2 years of disease onset using raw and inverse probability of treatment weighting (IPTW) analyses. RESULTS In the study population of 813 patients with OMG, 425 (52.3%) with immunosuppression had a mean (SD) onset age of 50.0 (15.1) years, and 188 (44.2%) were women. The remaining 388 (47.7%) patients were not immunosuppressed (mean age, 48.4 [15.0] years; 185 [47.7%] women). Disease generalization developed in 122 (31.4%) and 37 (8.7%) patients in the non-immunosuppression and immunosuppression groups, respectively. Relative to non-immunosuppression, immunosuppression was associated with a lower risk of generalization in a multivariable-adjusted Cox model (hazard ratio [HR], 0.27; 95% confidence interval [CI], 0.18-0.40; P<0.001) and IPTW-weighted Cox model (HR, 0.28; 95% CI, 0.19-0.42; P<0.001). In sensitivity analyses, longer duration of immunosuppression was associated with a lower risk of generalization (HR, 0.90 for every one-month increase; 95% CI, 0.87-0.92; P<0.001; IPTW-adjusted). Combination therapy with steroids and non-steroidal immunosuppressants showed superior efficacy in reducing the risk of generalization (HR, 0.14; 95% CI, 0.07-0.26; P<0.001). CONCLUSIONS Immunosuppression significantly reduced the 2-year risk of generalization in patients with OMG.
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Affiliation(s)
- Zhe Ruan
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Rongjing Guo
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Feng Gao
- Department of Neuroimmunology, BGI College & Henan Institute of Medical and Pharmaceutical Sciences in Academy of Medical Science, Zhengzhou University Zhengzhou
| | - Ye Lin
- Department of Neurology, The People's Liberation Army General Hospital, Beijing, China
| | - Quan Xu
- Department of Thoracic Surgery, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Liping Yu
- Department of Neurology, Xianyang First People's Hospital, Xianyang, China
| | - Songdi Wu
- Department of Neurology, Xi'an No.1 Hospital, Xi'an, China
| | - Tao Lei
- Department of Neurology, Xi'an Fourth People's Hospital, Xi'an, China
| | - Min Zhang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yanwu Gao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Xiaodan Lu
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Huanhuan Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Chao Sun
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Baoli Tang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, China
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13
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Treatment and Management of Disorders of the Neuromuscular Junction. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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14
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Guo RJ, Gao T, Ruan Z, Zhou HY, Gao F, Xu Q, Yu LP, Wu SD, Lei T, Li HH, Sun C, Zhang M, Gao YW, Lu XD, Tang YL, Tang BL, Huo FY, Zhu Y, Li ZY, Chang T. Risk Factors for Generalization in Patients with Ocular Myasthenia Gravis: A Multicenter Retrospective Cohort Study. Neurol Ther 2021; 11:73-86. [PMID: 34729706 PMCID: PMC8857387 DOI: 10.1007/s40120-021-00292-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/14/2021] [Indexed: 02/08/2023] Open
Abstract
Introduction Many patients with ocular myasthenia gravis (OMG) progress to generalized disease within the first 2 years of the onset of ocular symptoms. Several retrospective studies have identified risk factors associated with generalization, however these studies included patients on immunosuppression therapy or those undergoing thymectomy, which may reduce the generalization risk. In this study we explored the risk factors for generalization in non-immunosuppressed and non-thymectomized patients with OMG. Methods Data from patients with OMG treated at seven tertiary hospitals in China were retrospectively reviewed. Clinical characteristics, including sex, age at onset, symptoms at onset, comorbid autoimmune diseases, neostigmine test response, repetitive nerve stimulation (RNS) findings, presence of serum anti-acetylcholine receptor antibody (AChR-Ab), and thymic status based on radiological and pathological studies, were collected. The main outcome measure was disease generalization. The follow-up period was defined as the date of ocular symptom onset to the date of confirmation of generalization or immunotherapy initiation, or last follow-up (defined as 60 months). The Cox proportional hazards model was used to assess the risk factors for generalization. Results Overall, 572 patients (269 women) were eligible for inclusion in the analysis, of whom 144 developed generalization. The mean (standard deviation) onset age was 45.5 (19.8) years, and the median (interquartile range) follow-up period was 14.5 (7.0–47.3) months. Multivariable Cox regression analysis demonstrated that both early-onset (adjusted hazard ratio [aHR] 5.34; 95% confidence interval [CI] 1.64–17.36; p = 0.005) and late-onset (aHR 7.18; 95% CI 2.22–23.27; p = 0.001) in adulthood, abnormal RNS findings (aHR 3.01; 95% CI 1.97–4.61; p < 0.001), seropositivity for AChR-Ab (aHR 2.58; 95% CI 1.26–5.26; p = 0.01), and thymoma (aHR 1.62; 95% CI 1.05–2.49; p = 0.03) were independently associated with increased risk of generalization. Conclusion The risk of generalization increased significantly in patients with adult-onset OMG, abnormal RNS findings, seropositivity for AChR-Ab, and thymoma, suggesting that these risk factors may predict OMG generalization. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-021-00292-x.
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Affiliation(s)
- Rong-Jing Guo
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Ting Gao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Hong-Yu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Quan Xu
- Department of Thoracic Surgery, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Li-Ping Yu
- Department of Neurology, Xianyang First People's Hospital, Xianyang, China
| | - Song-Di Wu
- Department of Neurology, Xi'an No.1 Hospital, Xi'an, China
| | - Tao Lei
- Department of Neurology, Xi'an Fourth Hospital, Xi'an, China
| | - Huan-Huan Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Chao Sun
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Min Zhang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Yan-Wu Gao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Xiao-Dan Lu
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Yong-Lan Tang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Bao-Li Tang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Fei-Yan Huo
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Ying Zhu
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China
| | - Zhu-Yi Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China.
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, 710038, China.
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15
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Li H, Ruan Z, Gao F, Zhou H, Guo R, Sun C, Xu Q, Lu Q, Zhou Y, Zhao Z, Yu L, Wu S, Lei T, Gao T, Tang Y, Li C, Huo F, Zhu Y, Sun J, Tang B, Zhang M, Gao Y, Lu X, Li Z, Chang T. Thymectomy and Risk of Generalization in Patients with Ocular Myasthenia Gravis: A Multicenter Retrospective Cohort Study. Neurotherapeutics 2021; 18:2449-2457. [PMID: 34625864 PMCID: PMC8804035 DOI: 10.1007/s13311-021-01129-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 02/05/2023] Open
Abstract
This study aims to investigate the association between thymectomy and the risk of generalization in patients with ocular myasthenia gravis (MG). Data on patients with ocular MG from seven neurological centers in China were retrospectively reviewed. Ocular MG naïve to immunotherapy was categorized according to whether thymectomy was performed (thymectomized group vs. nonsurgical group). Patients in the thymectomized group all underwent surgery within 2 years since ocular symptom onset. The main outcome measure was the generalization. The follow-up period was defined from the date of ocular symptom onset to the date of generalization confirmation, immunotherapy initiation, or last follow-up (defined as 60 months). Of 519 eligible patients (mean [SD] age, 48.7 [15.2] years, 46.6% women), 31 (23.7%) of 131 generalized in the thymectomized group and 122 (31.4%) of 388 did in the nonsurgical group during a median follow-up of 19 months (IQR 8.0-50.0). Thymectomy was independently associated with reduced generalization risk (adjusted HR 0.41, 95% CI 0.25-0.66, P < 0.001). Multivariable stratified analysis also verified this association across the subgroups. Kaplan-Meier curves showed that the 5-year cumulative rate was significantly lower in the thymectomized group than in the nonsurgical group. To conclude, thymectomy may be considered effective in modifying the progression from ocular to generalized MG irrespective of thymoma.
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Affiliation(s)
- Huanhuan Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Feng Gao
- Department of Neuroimmunology, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Rongjing Guo
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Chao Sun
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Quan Xu
- Department of Thoracic Surgery, Jiangxi Provincial People's Hospital Affiliated To Nanchang University, Nanchang, China
| | - Qiang Lu
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yongan Zhou
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Zhengwei Zhao
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi'an, China
| | - Liping Yu
- Department of Neurology, Xianyang First People's Hospital, Xianyang, China
| | - Songdi Wu
- Department of Neurology, Xi'an No.1 Hospital, Xi'an, China
| | - Tao Lei
- Department of Neurology, Xi'an Fourth Hospital, Xi'an, China
| | - Ting Gao
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Yonglan Tang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Chunhong Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Feiyan Huo
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Ying Zhu
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Jie Sun
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Baoli Tang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Min Zhang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Yanwu Gao
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Xiaodan Lu
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China.
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 XinSi Road, Xi'an, 710038, China.
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Li F, Li Z, Chen Y, Bauer G, Uluk D, Elsner A, Swierzy M, Ismail M, Meisel A, Rückert JC. Thymectomy in ocular myasthenia gravis before generalization results in a higher remission rate. Eur J Cardiothorac Surg 2021; 57:478-487. [PMID: 31628812 DOI: 10.1093/ejcts/ezz275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 08/31/2019] [Accepted: 09/11/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES This study aimed to compare the outcomes of patients with ocular myasthenia gravis (OMG) who underwent thymectomy before generalization with the outcomes of those who underwent thymectomy after generalization. METHODS We retrospectively reviewed patients who underwent robotic thymectomy for myasthenia gravis between January 2003 and February 2018. Patients who presented with purely ocular symptoms at myasthenia gravis onset were eligible for inclusion. Exclusion criteria were patients who were lost to follow-up and patients who underwent re-thymectomy. Patients with OMG who developed generalization before thymectomy were categorized into gOMG group and those who did not were categorized into OMG group. The primary outcome was complete stable remission according to the Myasthenia Gravis Foundation of America Post-Intervention Status (MGFA-PIS). RESULTS One hundred and sixty-five (66 males and 99 females) out of 596 patients with myasthenia gravis were eligible for inclusion. Of these, there were 73 and 92 patients undergoing thymectomy before and after the generalization of OMG, respectively. After propensity score matching, a data set of 130 patients (65 per group) was formed and evaluating results showed no statistical differences between the 2 groups. The estimated cumulative probabilities of complete stable remission at 5 years were 49.5% [95% confidence interval (CI) 0.345-0.611] in the OMG group and 33.4% (95% CI 0.176-0.462) in the gOMG group (P = 0.0053). Similar results were also found in patients with non-thymomatous subgroup [55 patients per group, OMG vs gOMG, 53.5% (95% CI 0.370-0.656) vs 28.9% (95% CI 0.131-0.419), P = 0.0041]. CONCLUSIONS Thymectomy in OMG before generalization might result in a higher rate of complete stable remission than thymectomy after generalization.
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Affiliation(s)
- Feng Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Zhongmin Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Yanli Chen
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Gero Bauer
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Deniz Uluk
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Aron Elsner
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Marc Swierzy
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Mahmoud Ismail
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology, Integrated Center for Myasthenia Gravis, NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Charité - University Medicine Berlin, Berlin, Germany
| | - Jens-C Rückert
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Berlin, Germany
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Jain R, Aulakh R. Pediatric Ocular Myasthenia Gravis: A Review. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1721401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractPediatric ocular myasthenia gravis (OMG) is difficult to diagnose and manage, owing to its rarity and low index of suspicion in the early stage of the disease. Also, many other conditions having similar presentation cause a further delay in diagnosis. In this review, we highlighted various pointers in history and described bedside clinical tests that can aid in its timely diagnosis. The antibody spectrum in myasthenia is ever increasing and includes anti-muscle specific kinase and low-density lipoprotein-receptor related protein 4 antibodies in addition to acetylcholine receptor antibodies besides many others. However, pediatric OMG patients often test negative for all three antibodies, making the diagnosis even more difficult in triple seronegative patients. Edrophonium and electrophysiological tests, which help in confirming myasthenia in adults, have a limited utility in diagnosing pediatric ocular myasthenia cases. Various practical difficulties are encountered like nonavailability of edrophonium, risk of bradycardia associated with neostigmine use and its lower sensitivity, noncooperative children, and limited technical expertise in performing electrophysiological tests in children. In this article, we described a pragmatic approach to diagnose pediatric OMG along with the important aspects of its management.
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Affiliation(s)
- Reena Jain
- Department of Pediatrics, Government Medical College & Hospital, Chandigarh, India
| | - Roosy Aulakh
- Department of Pediatrics, Government Medical College & Hospital, Chandigarh, India
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Witthayaweerasak J, Rattanalert N, Aui-aree N. Prognostic factors for conversion to generalization in ocular myasthenia gravis. Medicine (Baltimore) 2021; 100:e25899. [PMID: 34106649 PMCID: PMC8133228 DOI: 10.1097/md.0000000000025899] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/22/2021] [Indexed: 11/25/2022] Open
Abstract
Patients with ocular myasthenia gravis (OMG) are frequently treated to prevent the development of generalized myasthenia gravis (GMG). This retrospective cohort study aimed to assess prognostic factors associated with conversion to GMG.We analyzed the time from the onset of OMG symptoms to GMG in relation to demographic variables, clinical findings, initial investigation results, and treatment regimens using Kaplan-Meier survival curves and multivariate Cox proportional regression analysis.Of 115 patients diagnosed with OMG (median follow-up time, 2.9 years), 28 (30.4%) developed GMG. The 2-year probability of GMG conversion was 23.7%. Patients with thymic abnormalities and a positive response to repetitive facial nerve stimulation had a significantly higher risk than those with negative results (hazard ratios [HR] 4.28, P < .001 and HR 3.84, P = .04, respectively). Treatment with immunosuppressants was found to be a preventive factor for secondary generalization (HR 0.36, P = .02).Patients with OMG had a low risk of developing GMG. Immunosuppressive treatments may mitigate disease progression. Chest imaging and repetitive nerve stimulation should be routinely performed to assess the risk of generalization.
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Kim KH, Kim SW, Shin HY. Initial Repetitive Nerve Stimulation Test Predicts Conversion of Ocular Myasthenia Gravis to Generalized Myasthenia Gravis. J Clin Neurol 2021; 17:265-272. [PMID: 33835748 PMCID: PMC8053540 DOI: 10.3988/jcn.2021.17.2.265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/03/2021] [Accepted: 02/03/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose A major concern with ocular myasthenia gravis (MG) is the potential conversion to generalized MG. This study was conducted to determine if the repetitive nerve stimulation (RNS) test could predict the conversion from ocular to generalized MG. Methods The RNS test was conducted in a consistent manner on five muscles in the face and limbs in every patient. Subjects were divided into those who remained as ocular MG (ROMG group) and those who experienced conversion to generalized MG during follow-up (GOMG group). Results Conversion to generalized MG occurred in 24 (21.4%) of 112 MG patients with ocular onset. The proportion of patients displaying abnormal decreases in responses in the trapezius, abductor digiti minimi, or flexor carpi ulnaris muscles on the RNS test was higher in the GOMG group (p<0.001, p=0.002, and p<0.001, respectively). The Cox proportional-hazards model revealed that an abnormal result on the RNS test was significantly associated with conversion to generalized MG [hazard ratio (HR)=3.13, 95% confidence interval (CI)=1.18–8.32]. Notably, the HR was higher for abnormal results on the RNS test for the limb muscles, at 5.19 (95% CI=2.09–12.90). Conclusions An abnormal result on the RNS test, especially in the limb muscles, is an independent predictor of the conversion from ocular to generalized MG. Applying the RNS test to limb muscles could be useful for predicting the conversion to generalized MG in patients with ocular onset.
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Affiliation(s)
- Ki Hoon Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.
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Deymeer F. Myasthenia gravis: MuSK MG, late-onset MG and ocular MG. ACTA MYOLOGICA : MYOPATHIES AND CARDIOMYOPATHIES : OFFICIAL JOURNAL OF THE MEDITERRANEAN SOCIETY OF MYOLOGY 2021; 39:345-352. [PMID: 33458590 PMCID: PMC7783433 DOI: 10.36185/2532-1900-038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/17/2020] [Indexed: 11/03/2022]
Abstract
Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction which affects all striated muscles, resulting in fluctuating weakness. Approaching MG as a disease with subgroups having different clinical, serological and genetic features is crucial in predicting the progression and planning treatment. Three relatively less frequently seen subtypes of MG are the subject of this review: MG with anti-MuSK antibodies (MuSK MG), non-thymomatous late-onset MG (LOMG), and ocular MG (OMG). In addition to reviewing the literature, mainly from a clinical point of view, our experience in each of the subgroups, based on close to 600 patients seen over a 10 year period, is related. MuSK MG is a severe disease with predominant bulbar involvement. It is more common in women and in early-onset patients. With the use of high dose corticosteroids, azathioprine and more recently rituximab, outcome is favorable, though the patients usually require higher maintenance doses of immunosuppressives. LOMG with onset ≥ 50 years of age is more common in men and ocular onset is common. Frequency of anti-AChR and anti-titin antibodies are high. Although it can be severe in some patients, response to treatment is usually very good. OMG is reported to be more frequent in men in whom the disease has a later onset. Anti-AChR antibodies are present in about half of the patients. Generalization is less likely when symptoms remain confined to ocular muscles for 2 years. Low dose corticosteroids are usually sufficient. Thyroid disease is the most common autoimmune disease accompanying all three subgroups.
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Affiliation(s)
- Feza Deymeer
- Department of Neurology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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Verma R, Wolfe GI, Kupersmith MJ. Ocular myasthenia gravis - How effective is low dose prednisone long term? J Neurol Sci 2020; 420:117274. [PMID: 33360170 DOI: 10.1016/j.jns.2020.117274] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Controversy persists on the best treatment to control ocular myasthenia gravis (OMG) and reduce conversion to generalized myasthenia gravis (GMG). We hypothesized that low dose prednisone could accomplish both in a cohort of OMG patients followed after three years. METHODS We reviewed the records of 168 patients who presented with OMG. Our study included 103 of the OMG patients who met inclusion criteria, requiring follow up for a minimum of 3 years without disease generalization. Low dose prednisone was defined as ≤7.5 mg per day. The main outcome was having single vision without ptosis blocking vision, measured by binocular single vision (BSV) and upper lid position. We also analyzed late progression to GMG. RESULTS Of 87 patients treated with prednisone, chronic low dose prednisone alone restored BSV in 47 patients (46% of all patients) without GMG. Pyridostigmine monotherapy restored BSV in 11/14 patients (11% of all patients). Other immunomodulatory therapy (OIT) was needed in 38 patients (37%). Medical therapy maintained BSV at last evaluation (mean follow up 8.2 ± 5.0 years) in 93 patients (90%). GMG developed in 10 patients (10%) during the follow-up period. CONCLUSION In OMG patients who do not generalize before 3 years, chronic long term prednisone at lower doses is moderately effective in maintaining optimum BSV. However, OIT are commonly required in these patients. In these OMG patients receiving prednisone and/or OIT, conversion to GMG after three years of disease is uncommon.
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Affiliation(s)
- Rashmi Verma
- Department of Neurology, Mount Sinai Beth Israel, New York, NY, United States of America
| | - Gil I Wolfe
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, Univ. at Buffalo/ SUNY, Buffalo, NY, United States of America
| | - Mark J Kupersmith
- Departments of Neurology, Ophthalmology & Neurosurgery, Icahn School of Medicine at Mount Sinai Hospitals and New York Eye and Ear Infirmary, New York, NY, United States of America.
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Evoli A, Iorio R. Controversies in Ocular Myasthenia Gravis. Front Neurol 2020; 11:605902. [PMID: 33329368 PMCID: PMC7734350 DOI: 10.3389/fneur.2020.605902] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
Myasthenia gravis (MG) with symptoms limited to eye muscles [ocular MG (OMG)] is a rare disease. OMG incidence varies according to ethnicity and age of onset. In recent years, both an increase in incidence rate, particularly in the elderly, and a lower risk for secondary generalization may have contributed to the growing disease prevalence in Western countries. OMG should be considered in patients with painless ptosis and extrinsic ophthalmoparesis. Though asymmetric muscle involvement and symptom fluctuations are typical, in some cases, OMG can mimic isolated cranial nerve paresis, internuclear ophthalmoplegia, and conjugate gaze palsy. Diagnostic confirmation can be challenging in patients negative for anti-acetylcholine receptor and anti-muscle-specific tyrosine kinase antibodies on standard radioimmunoassay. Early treatment is aimed at relieving symptoms and at preventing disease progression to generalized MG. Despite the absence of high-level evidence, there is general agreement on the efficacy of steroids at low to moderate dosage; immunosuppressants are considered when steroid high maintenance doses are required. The role of thymectomy in non-thymoma patients is controversial. Prolonged exposure to immunosuppressive therapy has a negative impact on the health-related quality of life in a proportion of these patients. OMG is currently excluded from most of the treatments recently developed in generalized MG.
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Affiliation(s)
- Amelia Evoli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raffaele Iorio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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Díaz-Maroto I, García-García J, Sánchez-Ayaso PA, Alcahut-Rodríguez C, González-Villar E, Pardal-Fernández JM, Segura T. Ocular myasthenia gravis and risk factors for developing a secondary generalisation: Description of a Spanish series. Neurologia 2020; 38:S0213-4853(20)30300-5. [PMID: 33208236 DOI: 10.1016/j.nrl.2020.09.004] [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: 06/24/2020] [Revised: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Ocular myasthenia gravis (MG) is the most common phenotype of MG at onset. A variable percentage of these patients develop secondary generalisation; the risk factors for conversion and the protective effect of immunosuppressive treatment are currently controversial. PATIENTS AND METHODS We designed a retrospective single-centre study with the aim of describing the demographic, clinical, and laboratory characteristics of a Spanish cohort of patients with ocular MG from Hospital Universitario de Albacete from January 2008 to February 2020. RESULTS We selected 62 patients with ocular MG from a cohort of 91 patients with MG (68.1%). Median age at diagnosis was 68 (IQR, 52-75.3), and men accounted for 61.3% of the sample (n = 38). Most patients presented very late-onset ocular MG (n = 34, 54.8%). Binocular diplopia was the most frequent initial symptom (51.7%). The rate of progression to generalised MG was 50% (n = 31), with a median time of 6 months (IQR, 2-12.8). Female sex (OR: 5.46; 95% CI, 1.16-25-74; p = .03) and anti-acetylcholine receptor antibodies (OR: 8.86; 95% CI, 1.15-68.41; p = .04) were significantly associated with the risk of developing generalised MG. CONCLUSIONS The conversion rate observed in our series is relatively high. Generalisation of MG mainly occurs during the first 2 years of progression, and is strongly associated with female sex and especially with the presence of anti-acetylcholine receptor antibodies.
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Affiliation(s)
- I Díaz-Maroto
- Servicio de Neurología del Complejo Hospitalario Universitario de Albacete, Albacete, España.
| | - J García-García
- Servicio de Neurología del Complejo Hospitalario Universitario de Albacete, Albacete, España
| | - P A Sánchez-Ayaso
- Servicio de Neurología del Hospital General Universitario Reina Sofía de Murcia, Murcia, España
| | - C Alcahut-Rodríguez
- Servicio de Neurología del Complejo Hospitalario Universitario de Albacete, Albacete, España
| | - E González-Villar
- Servicio de Neurología del Complejo Hospitalario Universitario de Albacete, Albacete, España
| | - J M Pardal-Fernández
- Neurofisiología Clínica del Complejo Hospitalario Universitario de Albacete, Albacete, España
| | - T Segura
- Servicio de Neurología del Complejo Hospitalario Universitario de Albacete, Albacete, España
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Update in immunosuppressive therapy of myasthenia gravis. Autoimmun Rev 2020; 20:102712. [PMID: 33197578 DOI: 10.1016/j.autrev.2020.102712] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/19/2020] [Indexed: 11/22/2022]
Abstract
Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction. Immunosuppressive treatments are part of the therapeutic armamentarium in MG. Long-term systemic steroid administration carry considerable risks and adverse events. Consequently, steroid-free immunosuppressive therapy is necessary to reduce the dose or discontinue steroids. First immunosuppressive drug trials in MG were performed in the mid-60s using standard and nonspecific immunosuppression. Since then, only few randomized controlled clinical trials were conducted in MG and assesed drug efficacy in terms of its steroid-sparing capacity and the ability to reduce myasthenic signs and symptoms. Treatment strategy in MG is quite challenging, mainly due to the disease heterogeneity in terms of clinical presentation, immunopathogenesis and drug response. To solve this dilemma, emerging treatment are based on biological drugs and use new targets of the immune pathway.
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25
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Narayanaswami P, Sanders DB, Wolfe G, Benatar M, Cea G, Evoli A, Gilhus NE, Illa I, Kuntz NL, Massey J, Melms A, Murai H, Nicolle M, Palace J, Richman D, Verschuuren J. International Consensus Guidance for Management of Myasthenia Gravis: 2020 Update. Neurology 2020; 96:114-122. [PMID: 33144515 PMCID: PMC7884987 DOI: 10.1212/wnl.0000000000011124] [Citation(s) in RCA: 242] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 10/08/2020] [Indexed: 12/23/2022] Open
Abstract
Objective To update the 2016 formal consensus-based guidance for the management of myasthenia gravis (MG) based on the latest evidence in the literature. Methods In October 2013, the Myasthenia Gravis Foundation of America appointed a Task Force to develop treatment guidance for MG, and a panel of 15 international experts was convened. The RAND/UCLA appropriateness method was used to develop consensus recommendations pertaining to 7 treatment topics. In February 2019, the international panel was reconvened with the addition of one member to represent South America. All previous recommendations were reviewed for currency, and new consensus recommendations were developed on topics that required inclusion or updates based on the recent literature. Up to 3 rounds of anonymous e-mail votes were used to reach consensus, with modifications to recommendations between rounds based on the panel input. A simple majority vote (80% of panel members voting “yes”) was used to approve minor changes in grammar and syntax to improve clarity. Results The previous recommendations for thymectomy were updated. New recommendations were developed for the use of rituximab, eculizumab, and methotrexate as well as for the following topics: early immunosuppression in ocular MG and MG associated with immune checkpoint inhibitor treatment. Conclusion This updated formal consensus guidance of international MG experts, based on new evidence, provides recommendations to clinicians caring for patients with MG worldwide.
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Affiliation(s)
- Pushpa Narayanaswami
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands.
| | - Donald B Sanders
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Gil Wolfe
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Michael Benatar
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Gabriel Cea
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Amelia Evoli
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Nils Erik Gilhus
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Isabel Illa
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Nancy L Kuntz
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Janice Massey
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Arthur Melms
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Hiroyuki Murai
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Michael Nicolle
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Jacqueline Palace
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - David Richman
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
| | - Jan Verschuuren
- From the Beth Israel Deaconess Medical Center/Harvard Medical School (P.N.), Boston, MA; Department of Neurology (D.B.S., J.M.), Duke University Medical Center, Durham, NC; Department of Neurology (G.W.), Univ. at Buffalo Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY; Department of Neurology (M.B.), University of Miami, Miller School of Medicine. Miami, FL; Gabriel Cea (G.C.), Departamento de Ciencias Neurologicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Dipartimento di Neuroscienze (A.E.), Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy; Department of Clinical Medicine (N.E.G.), University of Bergen, Norway; Isabel Illa (I.I.), Department of Neurology, Hospital Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, ERN EURO-NMD and CIBERER U762, Spain; Departments of Pediatrics and Neurology (N.L.K.), Northwestern Feinberg School of Medicine, Chicago, IL; Neurology (A.M.), University of Tübingen Medical Centre, Tübingen, Germany; Department of Neurology (H.M.), International University of Health and Welfare, Narita, Japan; Department of Clinical Neurological Sciences (M.N.), Western University, London, ON, Canada; Department of Clinical Neurology (J.P.), John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, UK; Department of Neurology (D.R.), University of California, Davis, Davis, CA; and Department of Neurology (J.V.), Leiden University Medical Centre, Leiden, the Netherlands
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Safety and Efficacy of the Under-Corrected Frontalis Sling in Myogenic Ptosis Accompanying Extraocular Muscle Paralysis. J Craniofac Surg 2020; 31:e802-e805. [PMID: 33136917 DOI: 10.1097/scs.0000000000006759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The surgical treatment of myogenic ptosis accompanying extraocular muscle paralysis is an intractable problem in the field of oculoplastic surgery due to the severe complications such as exposure keratopathy. It is promising to find an appropriate procedure to treat this kind of patients, which is able to ensure the safety and efficacy. METHODS The authors retrospectively reviewed 12 eyes of 6 patients who underwent the under-corrected "double V-Loop" frontalis suspension sling procedure for myogenic ptosis accompanying extraocular muscle paralysis and access the safety and efficacy of this kind of surgery. All the patients underwent corneal fluorescein staining and confocal microscopy before and after the surgery to inspect the corneal condition. The density of central corneal epithelial cells and endothelial cells were observed. RESULTS After the surgery, the eyelids contour was natural, and the symmetry was achieved in these cases. The average palpebral fissures height changed from 2.75 ± 1.41 mm to 4.50 ± 0.35 mm (P = 0.0007) and margin reflex distance 1 changed from -1.25 ± 1.22 mm to +0.50 ± 0.35 mm (P = 0.0002). Out of 12 operated eyes, mild postoperative lagophthalmos was present in 4 cases but without exposure keratopathy during the follow-up, the confocal microscopy showed that there were no significant differences in central corneal superficial epithelial cells (P = 0.93) and endothelial cells (P = 0.90) before and after the surgery. CONCLUSION The under-corrected "double V-Loop" frontalis suspension sling is a proper surgery in myogenic ptosis accompanying extraocular muscle paralysis, which leads to a low occurrence of exposure keratopathy, maintains the integrity of the cornea, and remains the patients' vision function.
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Shi M, Ye Y, Zhou J, Qin A, Cheng J, Ren H. Local use of dexamethasone in the treatment of ocular myasthenia gravis. BMC Ophthalmol 2020; 20:432. [PMID: 33115419 PMCID: PMC7594471 DOI: 10.1186/s12886-020-01697-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 10/14/2020] [Indexed: 11/24/2022] Open
Abstract
Background At present, patients with ocular myasthenia gravis (OMG) are typically treated with systemic drugs. We investigated the use of dexamethasone injected in the peribulbar region or extraocular muscle to treat patients with OMG. Methods Patients with OMG were given dexamethasone via peribulbar injection or direct injection into the main paralyzed extraocular muscles, once a week, for 4–6 weeks. The severity of diplopia, blepharoptosis, eye position, and eye movement were evaluated before and after treatment. The duration of follow-up time was ≥6 months. Results Among the 14 patients with OMG who received this treatment, mean age was 38.7 ± 29.7 years. After treatment, symptoms were relieved in 12 patients (85.7%), 1 patient (7.1%) had partial response to treatment, and 1 patient (7.1%) had no response. Two patients (14.2%) experienced symptom recurrence during the follow-up period. Conclusions Dexamethasone peribulbar or extraocular muscle injection is effective in the treatment of patients with OMG and may replace systemic drug therapy. Trial registration Chinese Clinical Trial Registry, ChiCTR2000038863, October 7, 2020.Retrospectively registered. Supplementary information The online version contains supplementary material available at 10.1186/s12886-020-01697-2.
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Affiliation(s)
- Minghua Shi
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China.
| | - Yingjia Ye
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China
| | - Junping Zhou
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China
| | - Aijiao Qin
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China
| | - Jing Cheng
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China
| | - Hongxing Ren
- Department of Strabismus and Pediatric Ophthalmology, Wuhan Aier Eye Hospital (Hanyang), Wuhan, 430020, China
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28
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Marotta DA, Jabaay MJ, Zadourian A, Kesserwani H. Bilateral Orbital Metastases Masquerading as Ocular Myasthenia Gravis: A Case Report and Review of the Literature. Cureus 2020; 12:e9105. [PMID: 32789050 PMCID: PMC7417125 DOI: 10.7759/cureus.9105] [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] [Indexed: 11/08/2022] Open
Abstract
Ocular myasthenia gravis and orbital metastases have overlapping symptoms but divergent diagnostic and treatment strategies. Here, we present a 58-year-old female, with a 20-year history of advanced metastatic breast cancer, who presented to the neurology clinic with fatigue, muscle weakness, bilateral ptosis, and diplopia that worsened throughout the day. While the initial presentation was consistent with ocular myasthenia gravis, a subsequent evaluation revealed bilateral metastatic lesions of breast origin within the orbits. This case highlights the variable nature of metastatic disease and underscores the importance of a comprehensive neoplastic workup in patients with new-onset symptomatology and a prior history of advanced cancer despite purported remission status.
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Affiliation(s)
- Dario A Marotta
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA.,Department of Neurology, Division of Neuropsychology, University of Alabama, Birmingham, USA
| | - Maxwell J Jabaay
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Adena Zadourian
- Department of Research, Alabama College of Osteopathic Medicine, Dothan, USA
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Feng X, Huan X, Yan C, Song J, Lu J, Zhou L, Wu H, Qiao K, Lu J, Xi J, Luo S, Zhao C. Adult Ocular Myasthenia Gravis Conversion: A Single-Center Retrospective Analysis in China. Eur Neurol 2020; 83:182-188. [PMID: 32526733 DOI: 10.1159/000507853] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/13/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The conversion rate from ocular myasthenia gravis (OMG) to generalized myasthenia gravis (GMG) was reported to be much lower in Asian population since most OMG patients are juvenile onset. However, the exact conversion rate for adult-onset OMG to GMG is still unknown. OBJECTIVE We aimed to delineate the conversion rate and risk factors for adult patients with ocular onset to GMG. METHODS Adult myasthenia gravis (MG) patients with ocular onset (age > 18 years) were retrospectively reviewed. Patients with confined ocular involvement lasting more than 2 years (pure OMG group) and those who converted into GMG (converted OMG group) were enrolled for subsequent analysis. We then analyzed 5 clinical variables, including onset age, sex, onset symptoms, anti-acetylcholine receptor antibody (AChR Ab), and thymus CT. Survival analysis was applied to all enrolled patients to explore risk factors associated with conversion. RESULTS In a total number of 249 ocular-onset MG patients initially enrolled, we excluded 122 patients with OMG lasting less than 2 years. The remaining 127 patients were enrolled, including 106 converted OMG and 21 pure OMG patients. Converted OMG patients had an older onset age (threshold: 43 years) and higher anti-AChR Ab titer (threshold: 6.13 nmol/L). The estimated conversion rate was 70.64%. Moreover, 67% of conversion occurred within 2 years after onset. Cox regression of survival analysis revealed that higher anti-AChR Ab titer and bilateral ptosis were associated with a higher conversion rate. CONCLUSIONS The conversion of adult OMG was associated with anti-AChR Ab titer, onset age, and bilateral ptosis. The estimated conversion rate of Chinese adult OMG patients was 70%.
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Affiliation(s)
- Xuelin Feng
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Xiao Huan
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Chong Yan
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Jie Song
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Jun Lu
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Lei Zhou
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Hui Wu
- Department of Neurology, Jing'an District Center Hospital of Shanghai, Shanghai, China
| | - Kai Qiao
- Department of Clinical Electromyography, Institute of Neurology, Huashan hospital Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Jianying Xi
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Sushan Luo
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China,
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30
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Ding J, Zhao S, Ren K, Dang D, Li H, Wu F, Zhang M, Li Z, Guo J. Prediction of generalization of ocular myasthenia gravis under immunosuppressive therapy in Northwest China. BMC Neurol 2020; 20:238. [PMID: 32527235 PMCID: PMC7288410 DOI: 10.1186/s12883-020-01805-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is well demonstrated that immunosuppressants can reduce, but not eliminate the risk of generalized development in ocular myasthenia gravis (OMG). In this study, we aimed to explore the predictive factors of generalized conversion of OMG patients who received immunosuppressive treatments. METHODS OMG patients under immunosuppressive treatments in Tangdu Hospital from June 2008 to June 2012 were retrospectively reviewed. Baseline clinical characteristics were documented. Patients were followed up regularly by face-to-face interview and the main outcome measure was generalized conversion. The logistic regression analysis was performed to determine the predictive factors of generalization of OMG. RESULTS Two hundred twenty-three eligible OMG patients completed the final follow-up visit and 38 (17.0%) progressed to generalized MG (GMG) at a median time to generalization of 0.9 year. Patients with adult onset and positive repetitive nerve stimulation (RNS) of facial or axillary nerve had higher conversion rate than those with juvenile onset and negative RNS (p = 0.001; p = 0.019; p = 0.015, respectively). Adult-onset patients converted earlier than juvenile-onset OMG patients (p = 0.014). Upon multivariate logistic regression analysis, age of onset (Odds ratio [OR] 1.023, 95% confidence interval [CI] 1.006-1.041, p = 0.007) and positive facial nerve RNS (OR 2.826, 95%CI 1.045-5.460, p = 0.038) were found to be positively associated with generalized development. Moreover, an obviously negative association was found for disease duration (OR 0.603, 95%CI 0.365-0.850, p = 0.019). CONCLUSIONS Age of onset, disease duration and facial nerve RNS test can predict generalized conversion of OMG under immunosuppressive therapy. Adult-onset, shorter disease duration and facial nerve RNS-positive OMG patients have a higher risk of generalized development.
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Affiliation(s)
- Jiaqi Ding
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, Shaanxi Province, China
| | - Sijia Zhao
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, Shaanxi Province, China
| | - Kaixi Ren
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, Shaanxi Province, China
| | - Dan Dang
- Intensive Care Unit, Xi'an Fourth Hospital, Xi'an, 710004, Shaanxi Province, China
| | - Hongzeng Li
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, Shaanxi Province, China
| | - Fang Wu
- Department of Neurology, Xi'an Children's Hospital, Xi'an, 710003, Shaanxi Province, China
| | - Min Zhang
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, Shaanxi Province, China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, Shaanxi Province, China.
| | - Jun Guo
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, Shaanxi Province, China.
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31
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Habib AA, Ahmadi Jazi G, Mozaffar T. Update on immune-mediated therapies for myasthenia gravis. Muscle Nerve 2020; 62:579-592. [PMID: 32462710 DOI: 10.1002/mus.26919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 05/04/2020] [Accepted: 05/07/2020] [Indexed: 11/05/2022]
Abstract
With the exception of thymectomy, immune modulatory treatment strategies and clinical trials in myasthenia gravis over the past 50 y were mainly borrowed from experience in other nonneurologic autoimmune disorders. The current experimental therapy paradigm has significantly changed such that treatments directed against the pathological mechanisms specific to myasthenia gravis are being tested, in some cases as the initial disease indication. Key advances have been made in three areas: (i) the expanded role and long-term benefits of thymectomy, (ii) complement inhibition to prevent antibody-mediated postsynaptic membrane damage, and (iii) neonatal Fc receptor (FcRn) inhibition as in vivo apheresis, removing pathogenic antibodies. Herein, we discuss these advances and the potential for these newer therapies to significantly influence the current treatment paradigms. While these therapies provide exciting new options with rapid efficacy, there are anticipated challenges to their use, especially in terms of a dramatic increase in cost of care for some patients with myasthenia gravis.
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Affiliation(s)
- Ali Aamer Habib
- Department of Neurology, University of California, Irvine, California
| | | | - Tahseen Mozaffar
- Department of Neurology, University of California, Irvine, California.,Department of Orthopedic Surgery, University of California, Irvine, California.,Departments of Pathology and Laboratory Medicine, University of California, Irvine, California
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32
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Liu X, Zhou W, Hu J, Hu M, Gao W, Zhang S, Zeng W. Prognostic predictors of remission in ocular myasthenia after thymectomy. J Thorac Dis 2020; 12:422-430. [PMID: 32274108 PMCID: PMC7139038 DOI: 10.21037/jtd.2020.01.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Identifying prognostic predictors can assist in making clinical decisions. This study aimed to identify the potential predictors of remission in patients with ocular myasthenia gravis (OMG) after thymectomy. Methods OMG patients who had thymectomy between 2011 and 2017 were reviewed retrospectively. Clinical outcomes were assessed according to the Myasthenia Gravis Foundation of America Post-Intervention Status (MGFA-PIS). Kaplan-Meier analysis was used to estimate the cumulative probability of complete stable remission (CSR). Univariate and multivariable analyses with Cox proportional hazards regression were used to identify predictors of CSR. Results Fifty-one patients (23 male, 28 female) with a median age at OMG onset of 40 (range, 5-79) years were eligible for inclusion. Patients with thymomatous OMG (n=9) had a statistically older median age at disease onset [61 (range, 32-78) vs. 33.5 (range, 5-79) years, P=0.001], shorter duration from disease onset to thymectomy [3 (range, 2-24) vs. 10 (range, 1-132) months, P=0.004], and a higher rate of postoperative complication (44.4% vs. 9.5%, P=0.025), compared with non-thymomatous OMG (n=42). The estimated cumulative probability of CSR in the whole cohort was 41.8% (95% CI, 28.6-58.2%) 5 years after surgery. Age at onset of 40 years or younger (P=0.00016), female sex (P=0.069), and thymic hyperplasia (P=0.0061) were potential predictors under univariate analysis. However, only age at onset of 40 years or younger (HR: 4.117, 95% CI, 1.177-14.399, P=0.027) remained significant after multivariable analysis. Conclusions CSR could be achieved in about 40% of OMG patients 5 years after thymectomy and is likely to be predicted by age at onset of 40 years or younger.
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Affiliation(s)
- Xiang Liu
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Wangyan Zhou
- Department of Medical Humanities and Education Department, the First Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Jun Hu
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Mingsong Hu
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Wenkui Gao
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Shan Zhang
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
| | - Wei Zeng
- Department of Cardiothoracic Surgery, the Second Affiliated Hospital, University of South China, Hengyang 421001, China
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Apinyawasisuk S, Chongpison Y, Thitisaksakul C, Jariyakosol S. Factors Affecting Generalization of Ocular Myasthenia Gravis in Patients With Positive Acetylcholine Receptor Antibody. Am J Ophthalmol 2020; 209:10-17. [PMID: 31562855 DOI: 10.1016/j.ajo.2019.09.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 01/22/2023]
Abstract
PURPOSE To evaluate the associated factors of conversion of ocular myasthenia gravis (OMG) to generalized myasthenia gravis (GMG) among patients with seropositive acetylcholine receptor antibody (AchR Ab). DESIGN Retrospective cohort study. METHODS Setting: Retrospective chart review. PATIENT Seventy-one OMG patients with seropositive AchR Ab presented during July 2009 and December 2016. The exclusion criteria were patients who (1) first presented with GMG, (2) were unable to identify the time of onset of OMG or GMG, (3) were unable to provide information about previous treatments before the onset of GMG, and (4) had incomplete or lost medical records. OBSERVATION PROCEDURE We collected demographic and clinical characteristics, including onset of OMG and GMG, presence of other autoimmune disorders, history of smoking, presence of thymic abnormalities, and medications received. MAIN OUTCOME MEASURES Conversion to GMG and time to conversion. RESULTS Thirty-six patients experienced conversion to GMG. Overall incidence of GMG was 14 (95% confidence interval [CI] 10.09-19.4) per 100 patient-years. Probability of conversion at 2 years was .37 (95% CI .27-.49). Overall median conversion time was 4.97 years. Cox proportional hazard model showed that risk factors were female sex (HR 2.52, 95% CI 1.04-6.10), history of smoking (HR 3.42, 95% CI 1.40-8.45), and thymic abnormalities (HR 1.82, 95% CI 0.91-3.67). Protective factors against conversion to GMG were receiving immunosuppressive agents (HR 0.42, 95% CI 0.19-0.97) and pyridostigmine (HR 0.37, 95% CI 0.14-0.93). CONCLUSIONS OMG patients with seropositive AchR Ab should be informed that taking pyridostigmine and/or immunosuppressive agents as well as smoking cessation might prevent conversion to GMG.
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Affiliation(s)
- Supanut Apinyawasisuk
- Ophthalmology Department, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Yuda Chongpison
- Biostatistic Excellence Center, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Supharat Jariyakosol
- Ophthalmology Department, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Maintenance immunosuppression in myasthenia gravis, an update. J Neurol Sci 2019; 410:116648. [PMID: 31901719 DOI: 10.1016/j.jns.2019.116648] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/25/2019] [Accepted: 12/24/2019] [Indexed: 01/08/2023]
Abstract
Therapies for myasthenia gravis (MG) include symptomatic and immunosuppressive/immunomodulatory treatment. Options for immunosuppression include corticosteroids, azathioprine, mycophenolate mofetil, cyclosporine, tacrolimus, methotrexate, rituximab, cyclophosphamide, eculizumab, intravenous immunoglobulin, subcutaneous immunoglobulin, plasmapheresis, and thymectomy. The practical aspects of long-term immunosuppressive therapy in MG are critically reviewed in this article. Application of one or more of these specific therapies is guided based on known efficacy, adverse effect profile, particular disease subtype and severity, and patient co-morbidities.
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Farmakidis C, Dimachkie MM, Pasnoor M, Barohn RJ. Immunosuppressive and immunomodulatory therapies for neuromuscular diseases. Part I: Traditional agents. Muscle Nerve 2019; 61:5-16. [DOI: 10.1002/mus.26708] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/05/2019] [Accepted: 09/07/2019] [Indexed: 12/23/2022]
Affiliation(s)
| | - Mazen M. Dimachkie
- Neurology Department University of Kansas Medical Center Kansas City Kansas
| | - Mamatha Pasnoor
- Neurology Department University of Kansas Medical Center Kansas City Kansas
| | - Richard J. Barohn
- Neurology Department University of Kansas Medical Center Kansas City Kansas
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Xu L, Castro D, Reisch JS, Iannaccone ST. Response to treatment in pediatric ocular myasthenia gravis. Muscle Nerve 2019; 61:226-230. [PMID: 31650555 DOI: 10.1002/mus.26745] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Juvenile myasthenia gravis (JMG), a pediatric autoimmune neuromuscular junction disorder, includes generalized (GMG), and ocular (OMG) variants. We sought to determine whether differences existed between OMG and GMG children regarding demographics or treatment response. METHODS We performed retrospective analysis of 60 children with JMG seen between 1990 and 2018. Osserman scores were used to define OMG and GMG. The myasthenia scale of Millichap and Dodge was used to assess treatment responses. RESULTS There were no differences between GMG and OMG regarding time interval from disease onset to prednisone initiation (P = .42), or treatment response according to Millichap and Dodge (P = .12). Compared with GMG, OMG children showed younger age of disease onset and better outcomes after treatment. No OMG patients progressed to generalized disease during the follow-up period. DISCUSSION Compared with GMG, OMG patients had earlier disease onset and improved outcomes after treatment.
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Affiliation(s)
| | - Diana Castro
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joan S Reisch
- Division of Biostatistics, Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Susan T Iannaccone
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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Li M, Ge F, Guo R, Ruan Z, Gao Y, niu C, Lin H, Zhao Z, Zhou Y, Li Z, Chang T. Do early prednisolone and other immunosuppressant therapies prevent generalization in ocular myasthenia gravis in Western populations: a systematic review and meta-analysis. Ther Adv Neurol Disord 2019; 12:1756286419876521. [PMID: 35173803 PMCID: PMC8842340 DOI: 10.1177/1756286419876521] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/25/2019] [Indexed: 01/19/2023] Open
Abstract
Background: The majority of ocular myasthenia gravis (OMG) patients will progress to
generalized myasthenia gravis (GMG), usually within 2 years of disease
onset. The aim of this meta-analysis was to evaluate the effect of early
prednisolone and other immunosuppressants therapy on the generalization rate
in OMG patients. Methods: We searched the CENTRAL, EMBASE, and MEDLINE databases via
the Ovid SP database for all relevant publications on 16 July 2018. Results: Eight studies comprising a total of 547 participants were included in our
meta-analysis. Compared with pyridostigmine treatment, prednisolone and
other immunosuppressants therapy produced an odds ratio (OR) for the
development of GMG of 0.19 [95% confidence interval (CI), 0.11–0.30;
I2 = 37%], indicating that early
prednisolone and other immunosuppressants therapy reduced the generalization
rate in OMG by 81%. Conclusions: Early prednisolone and other immunosuppressants therapy can significantly
reduce the risk of generalization in OMG patients, and should be considered
in newly diagnosed OMG patients. Due to the inclusion of retrospective
studies, this noted effect might have been related to corticosteroids,
especially when immunosuppressants used at low dosages and in mild disease.
Additionally, the data derived from Western populations, thus a prospective
randomized controlled trial (RCT) is warranted to confirm this effect of
early prednisolone and other immunosuppressants therapy on OMG
generalization both in Western and Asian populations.
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Affiliation(s)
- Mingxia Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi’an, Shaanxi Province, P.R. China
| | - Fangfang Ge
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi’an, Shaanxi Province, P.R. China
| | - Rongjing Guo
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi’an, Shaanxi Province, P.R. China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi’an, Shaanxi Province, P.R. China
| | - Yanwu Gao
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi’an, Shaanxi Province, P.R. China
| | - Chunxiao niu
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi’an, Shaanxi Province, P.R. China
| | - Hong Lin
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, Xi’an, Shaanxi Province, P.R. China
| | - Zhengwei Zhao
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi’an, Shaanxi Province, P.R. China
| | - Yongan Zhou
- Department of Thoracic Surgery, Tangdu Hospital, the Fourth Military Medical University, Xi’an, Shaanxi Province, P.R. China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 Xinsi Road, Xi’an 710038, Shaanxi Province, P.R. China
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, the Fourth Military Medical University, 569 Xinsi Road, Xi’an 710038, Shaanxi Province, P.R. China
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Hendricks TM, Bhatti MT, Hodge DO, Chen JJ. Incidence, Epidemiology, and Transformation of Ocular Myasthenia Gravis: A Population-Based Study. Am J Ophthalmol 2019; 205:99-105. [PMID: 31077669 DOI: 10.1016/j.ajo.2019.04.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/23/2019] [Accepted: 04/26/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE To establish the incidence of ocular myasthenia gravis (OMG) as well as identify determinants of transformation to generalized myasthenia gravis (GMG) using a population-based record-linkage system. DESIGN Population-based, retrospective cohort study. METHODS All adults (≥18 years) diagnosed with myasthenia gravis (MG) from January 1, 1990, through December 31, 2017, were identified using the Rochester Epidemiology Project. Sixty-five patients with MG were identified. Data were collected regarding symptom onset, diagnostic testing results, and conversion from OMG to GMG. RESULTS Median follow-up time was 91 months (range 17-333 months). The annual incidence of MG was 2.20/100 000 with a mean age at diagnosis of 59 years (SD=17) and 62% male sex. Thirty-three (51%) of the 65 patients presented with OMG, providing an annual incidence of 1.13/100 000. Eighteen (55%) of the 33 patients presenting with OMG converted to GMG at a median time of 13 months (range 2-180 months). Sixteen (67%) of 24 OMG patients who were seropositive for acetylcholine receptor antibody (AchR Ab) converted to GMG at 5 years compared to 11% (1/9) of those who were seronegative (hazard ratio [HR], 8.2, P = .04). Ten (77%) of 13 OMG patients with a positive single-fiber electromyography (sfEMG) at diagnosis converted to GMG at 5 years, compared with 18% (2/11) of patients who had a negative sfEMG (HR, 5.5, P = .01). CONCLUSIONS In our population-based study, 51% (33/65) of patients with MG presented with isolated ocular involvement, with 55% (18/33) of these patients converting to GMG at some point in the course of their disease. Positive sfEMG and AchR Ab seropositivity at the time of diagnosis increased the risk of conversion to GMG.
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Affiliation(s)
- Tina M Hendricks
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - M Tariq Bhatti
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - John J Chen
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.
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Abstract
With specialized care, patients with myasthenia gravis can have very good outcomes. The mainstays of treatment are acetylcholinesterase inhibitors, and immunosuppressive and immunomodulatory therapies. There is good evidence thymectomy is beneficial in thymomatous and nonthymomatous disease. Nearly all of the drugs used for MG are considered "off-label." The 2 exceptions are acetylcholinesterase inhibitors and complement inhibition with eculizumab, which was recently approved by the US Food and Drug Administration for myasthenia gravis. This article reviews the evidence base and provides a framework for the treatment of myasthenia gravis, highlighting recent additions to the literature.
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Li F, Hotter B, Swierzy M, Ismail M, Meisel A, Rückert JC. Generalization after ocular onset in myasthenia gravis: a case series in Germany. J Neurol 2018; 265:2773-2782. [PMID: 30225725 DOI: 10.1007/s00415-018-9056-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 08/22/2018] [Accepted: 09/08/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Approximately, 50% of myasthenia gravis (MG) patients initially present with purely ocular symptoms. Of these, about 60% will develop secondary generalized MG, typically within 2 years. Risk factors for secondary generalization are still controversial. In this study, we reviewed clinical parameters, thymic pathologies and medical treatments of MG patients with purely ocular symptoms at onset to investigate risk factors for secondary generalization. METHODS In this monocentric retrospective study, we reviewed consecutive patients who underwent robotic thymectomy between January 2003 and October 2017 in Charite Universitaetsmedizin Berlin. We used univariate and multivariate Cox proportional hazards regression models to identify factors associated with secondary generalization. Survival curves were plotted using Kaplan-Meier method and log-rank tests were performed to analyze the association between corticosteroids use and secondary generalization in subgroups defined by anti-AChR antibody status and thymic pathology. RESULTS One hundred and eighty of 572 MG patients who underwent robotic thymectomy were eligible for inclusion, of whom 110 (61.1%) developed a secondary generalized MG over a mean follow-up time of 23.6 months. The presence of a thymoma (HR 1.659, 95% CI (1.52-2.617), P = 0.029) was the only risk factor for secondary generalization in our series. Treating with corticosteroids was associated with a lower conversion rate in ocular myasthenia patients with thymic hyperplasia (n = 55, P = 0.028), but not with other thymic pathologies including thymoma and normal or atrophic thymus. CONCLUSIONS The conversion rate in ocular myasthenia was high in our series, predicted by the presence of a thymoma. Our findings suggest that corticosteroids can prevent secondary generalization in ocular myasthenia patients with thymic hyperplasia, which requires further research.
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Affiliation(s)
- Feng Li
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Benjamin Hotter
- Department of Neurology Berlin, Charité University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Marc Swierzy
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Mahmoud Ismail
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Meisel
- Department of Neurology Berlin, Charité University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Jens-C Rückert
- Department of Surgery, Competence Center of Thoracic Surgery, Charité University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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Abstract
Myasthenia gravis is a relatively common neuromuscular disorder, with ocular myasthenia gravis being a subset defined as myasthenia gravis limited to the orbicularis, levator, and extraocular muscles. Patients with ocular myasthenia gravis can have disabling diplopia or functional blindness from ptosis and in most cases treatment is required. Like generalized myasthenia gravis, there are a variety of treatments available that include pyridostigmine, immunosuppression, intravenous immunoglobulin, plasmapheresis, thymectomy, lid crutches, ptosis surgery, and extraocular muscle surgery. Unfortunately, there is limited data on the use of individual treatments in ocular myasthenia gravis and no data comparing treatments. Using a combination of available data on treatment of generalized myasthenia gravis, data on treatment of ocular myasthenia gravis, best practices, and clinical experience we will provide a rational framework for treatment of ocular myasthenia gravis.
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Affiliation(s)
- Wayne T Cornblath
- Departments of Ophthalmology & Visual Sciences and Neurology, W.K. Kellogg Eye Center, University of Michigan, MI
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Na SJ. Corticosteroids Treatment in Spinal Cord and Neuromuscular Disorders. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Teo KY, Tow SL, Haaland B, Gosavi TD, Jing-Liang L, Yew Long LO, Milea D. Low conversion rate of ocular to generalized myasthenia gravis in Singapore. Muscle Nerve 2017; 57:756-760. [PMID: 28981152 DOI: 10.1002/mus.25983] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Ocular myasthenia gravis (OMG) is a common condition of the neuromuscular junction that may convert to generalized myasthenia gravis (GMG). Our aim in this study was to determine the conversion rate and predictive factors for generalization in OMG, in an Asian population. METHODS The investigation consisted of a retrospective study of OMG patients with a minimum 2 years of follow-up. RESULTS Among 191 patients with OMG, 155 had the minimum 2-year follow-up. The conversion rate at median follow-up (40.8 months) was 10.6% (95% confidence interval 7.9%-13.3%), and at the 2-year follow-up it was 7.7% (95% confidence interval 5.6%-9.8%). At baseline, the predictive factors for generalization were positive acetylcholine receptor antibodies (hazard ratio 3.71, P = 0.024), positive repetitive nerve stimulation (RNS) studies (hazard ratio 4.42, P = 0.003), and presence of radiologically presumed or pathologically confirmed thymoma (hazard ratio 3.10, P = 0.013). DISCUSSION The conversion rate of OMG to GMG in Asian patients is low, as predicted by presence of acetylcholine receptor antibodies, presence of thymoma, and positive RNS studies. Muscle Nerve 57: 756-760, 2018.
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Affiliation(s)
| | - Sharon L Tow
- Singapore National Eye Centre, Singapore Eye Research Institute and Duke-NUS, Singapore
| | - Benjamin Haaland
- Population Health Sciences, University of Utah, USA and Duke-NUS, Singapore
| | - Tushar D Gosavi
- National Neuroscience Institute, Singapore General Hospital, Singapore
| | - Loo Jing-Liang
- Singapore National Eye Centre, Singapore Eye Research Institute, Yong Yoo Lin Medical School and Duke-NUS
| | - L O Yew Long
- National Neuroscience Institute, Singapore General Hospital, Singapore
| | - Dan Milea
- Singapore National Eye Centre, Singapore Eye Research Institute and Duke-NUS, Singapore
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Kamarajah SK, Sadalage G, Palmer J, Carley H, Maddison P, Sivaguru A. Ocular presentation of myasthenia gravis: A natural history cohort. Muscle Nerve 2017; 57:622-627. [PMID: 28881457 DOI: 10.1002/mus.25971] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2017] [Indexed: 11/07/2022]
Abstract
INTRODUCTION There are limited data on the natural history of untreated myasthenia gravis (MG) with ocular presentation. METHODS We analyzed 93 patients from symptom onset who presented to the Birmingham Midlands Eye Centre (BMEC) between January 2004 and July 2015. We used multiple stepwise logistic regression to identify predictive factors of generalization and Kaplan-Meier analysis on time to generalization. RESULTS Forty-six percent of patients developed generalized symptoms during the study period. Median time to generalization was 7 months. Time to generalization was earlier in patients seropositive for acetylcholine receptor (AChR) antibody (median 5 months vs. 21 months, P < 0.0001) and bilateral ptosis at onset (P = 0.015). Multivariate analysis identified AChR seropositivity [hazard ratio (HR) 5.03; 95% confidence interval (CI) 1.48-17.14; P = 0.001] and disease onset < 50 years (HR 3.58; 95% CI 1.18-10.90; P = 0.035) as risk factors for generalization. DISCUSSION As patients were steroid-naive before generalization, our cohort approximated the natural history of the condition. Muscle Nerve 57: 622-627, 2018.
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Affiliation(s)
- Sivesh K Kamarajah
- College of Medical and Dental Sciences, University of Birmingham, Vincent Drive, Birmingham, B15 2TT, UK
| | - Girija Sadalage
- Division of Neurology, University of Nottingham, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
| | - Jonathan Palmer
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Helena Carley
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Paul Maddison
- Division of Neurology, University of Nottingham, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
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Ocular Myasthenia Gravis: Toward a Risk of Generalization Score and Sample Size Calculation for a Randomized Controlled Trial of Disease Modification. J Neuroophthalmol 2017; 36:252-8. [PMID: 27031125 DOI: 10.1097/wno.0000000000000350] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There is currently no prognostic test to determine the risk of developing generalized myasthenia gravis (GMG) risk in patients who first present with ocular disease. Most studies that report risk factors are flawed by the inclusion of patients on immunosuppression, which is likely to reduce the risk. OBJECTIVE To create a prognostic score to predict the risk of GMG. METHODS Multicenter retrospective cohort of patients with ocular myasthenia gravis for minimum 3 months, untreated with immunosuppression for minimum 2 years or until GMG onset. RESULTS One hundred one (57 female) patients were included, with median follow-up of 8.4 years (2-42) from disease onset. Thirty-one developed GMG at median of 1.31 years (3.5 months-20.2 years); 19 occurred within 2 years. Univariable logistic regression analysis produced 3 significant predictors (P < 0.10), adjusted odds ratios in a multivariable logistic model (χ P = 0.01) with multiple imputations for missing data: seropositivity, 5.64 (95% CI, 1.45-21.97); presence of 1 or more comorbidities including autoimmune disorders, 6.49 (95% CI, 0.78-53.90); thymic hyperplasia, 5.41 (95% CI, 0.39-75.43). Prognostic score was derived from the coefficients of the logistic model: sum of the points (1 point for the presence of each of the above predictive factors), classified "low risk" if ≤1 and "high risk" if ≥2. Predicted probabilities were 0.07 (SD, 0.03) for low risk and 0.39 (SD, 0.09) for high risk. Negative predictive value was 91% (95% CI, 79-98), positive predictive value was 38% (95% CI, 23-54), sensitivity was 79% (95% CI, 54-94), specificity was 63% (95% CI, 50-74), area under receiver operating characteristic curve was 0.74 (95% CI, 0.64-0.85). CONCLUSIONS In this preliminary study, we have shown by proof of principle that it is possible to stratify risk of GMG: an approach that may allow us to better counsel patients at diagnosis, complement decision-making, and move us toward addressing the question of modifying GMG risk in high-risk patients. Furthermore, the effect of comorbidities is novel and demands further elucidation.
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Diagnostic Utility of Repetitive Nerve Stimulation in a Large Cohort of Patients With Myasthenia Gravis. J Clin Neurophysiol 2017; 34:400-407. [DOI: 10.1097/wnp.0000000000000398] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Myasthenia gravis. SPEKTRUM DER AUGENHEILKUNDE 2017. [DOI: 10.1007/s00717-017-0339-8] [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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Valko Y, Weber KP. [Not Available]. PRAXIS 2017; 106:1107-1114. [PMID: 28976252 DOI: 10.1024/1661-8157/a002796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Zusammenfassung. Die Kombination von fluktuierender und belastungsabhängiger Diplopie, Ptose und paretischem Lidschluss – unter Aussparung der Pupillomotorik – ist pathognomonisch für die okuläre Myasthenie. In den ersten zwei Jahren kommt es bei 80 % der Patienten zu einer Generalisierung, mit Entwicklung bulbärer Beschwerden und Schwäche in der Extremitätenmuskulatur. Die Diagnose der okulären Myasthenie gelingt wegen des oft schleichenden Auftretens, der schwierigen Abgrenzung zu anderen neuroophthalmologischen und neurologischen Krankheitsbildern und der niedrigen Sensitivität der apparativen Untersuchungen oft nur mit Verspätung. Eine rasche Diagnose ist wichtig, da effiziente Therapieoptionen eine gute Symptomkontrolle erlauben und weil eine frühe Immunsuppression die Häufigkeit der Konversion zu einer generalisierten Form reduzieren kann.
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Affiliation(s)
- Yulia Valko
- 1 Klinik für Neurologie, Universitätsspital Zürich
| | - Konrad P Weber
- 1 Klinik für Neurologie, Universitätsspital Zürich
- 2 Klinik für Ophthalmologie, Universitätsspital Zürich
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