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Jacob S. Treating myasthenia gravis beyond the eye clinic. Eye (Lond) 2024:10.1038/s41433-024-03133-x. [PMID: 38789789 DOI: 10.1038/s41433-024-03133-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/17/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Myasthenia gravis (MG) is one of the most well characterised autoimmune disorders affecting the neuromuscular junction with autoantibodies targeting the acetylcholine receptor (AChR) complex. The vast majority of patients present with ocular symptoms including double vision and ptosis, but may progress on to develop generalised fatiguable muscle weakness. Severe involvement of the bulbar muscles can lead to dysphagia, dysarthria and breathing difficulties which can progress to myasthenic crisis needing ventilatory support. Given the predominant ocular onset of the disease, it is important that ophthalmologists are aware of the differential diagnosis, investigations and management including evolving therapies. When the disease remains localised to the extraocular muscles (ocular MG) IgG1 and IgG3 antibodies against the AChR (including clustered AChR) are present in nearly 50% of patients. In generalised MG this is seen in nearly 90% patients. Other antibodies include those against muscle specific tyrosine kinase (MuSK) and lipoprotein receptor related protein 4 (LRP4). Even though decremental response on repetitive nerve stimulation is the most well recognised neurophysiological abnormality, single fibre electromyogram (SFEMG) in experienced hands is the most sensitive test which helps in the diagnosis. Initial treatment should be using cholinesterase inhibitors and then proceeding to immunosuppression using corticosteroids and steroid sparing drugs. Patients requiring bulbar muscle support may need rescue therapies including plasma exchange and intravenous immunoglobulin (IVIg). Newer therapeutic targets include those against the B lymphocytes, complement system, neonatal Fc receptors (FcRn) and various other elements of the immune system.
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Affiliation(s)
- Saiju Jacob
- University Hospitals Birmingham, Birmingham, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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Keovilayhong S, Mulliez A, Feral L, Chenaf C, Clavelou P, Moisset X, Taithe F, Poncet Megemont L. Epidemiology of myasthenia gravis in France: Incidence, prevalence, and comorbidities based on national healthcare insurance claims data. Rev Neurol (Paris) 2024; 180:451-458. [PMID: 38582663 DOI: 10.1016/j.neurol.2024.02.392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 12/13/2023] [Accepted: 02/09/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The European literature has reported high variability in the incidence and prevalence rates of myasthenia gravis (MG), but no specific epidemiological data for France have been published. This study aimed to assess the incidence and prevalence rates of myasthenia gravis in France based on data extracted from the French National Health Insurance Claims Database (the SNIIRAM database). METHODS We conducted a retrospective repeated cross-sectional population study from 2008 to 2018 using a representative sample of the French population (Échantillon généraliste des bénéficiaires) covered by health insurance. We calculated the incidence, prevalence, and sex ratio of MG and screened for comorbidities associated with MG (standardized to the general population). RESULTS In total, 331 MG patients were identified between 2008 and 2018. The average incidence of MG in France was 50 per million person-years, while the mean prevalence was 465 per million people. The female-to-male ratio was 1.33. The Incidence of MG gradually increased from 40years of age for women and 60 for men. Thymoma was present for 5.1% of MG patients and a thymectomy was performed for 4.7%. Thyroid disease was the most prevalent autoimmune comorbidity, affecting approximately 8.5% of cases. MG patients had an increased cancer risk, with a standardized rate ratio of 2.38 (95% CI: 1.64-3.46). CONCLUSION The incidence and prevalence rates of MG are significantly higher than those previously reported in the literature and the incidence increases with age. The excess risk of cancer raises concerns for MG patients, in particular, concerning the management of immunosuppressive drugs.
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Affiliation(s)
- S Keovilayhong
- Mittaphab Hospital, Vientiane, Lao Democratic People's Republic
| | - A Mulliez
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - L Feral
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - C Chenaf
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - P Clavelou
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France; Neuro-Dol, Inserm, Clermont-Ferrand, France
| | - X Moisset
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France; Neuro-Dol, Inserm, Clermont-Ferrand, France
| | - F Taithe
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - L Poncet Megemont
- Université Clermont Auvergne, CHU de Clermont-Ferrand, Clermont-Ferrand, France.
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Mu Y, Huang X, Yang Y, Huang Z, Chen J, Li S, Dong Y, Chen F, Zhang R, Chen J, Feng H, Zhou Q. Study of serum exosome miRNA as a biomarker for early onset adult ouclar myastthenia gravis. Gene 2024; 896:148034. [PMID: 38013129 DOI: 10.1016/j.gene.2023.148034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/13/2023] [Accepted: 11/24/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND By extracting and sequencing miRNAs from serum exosomes of patients with early-onset ocular myasthenia gravis (OMG), generalized myasthenia gravis (GMG) and healthy controls, we screened differentially expressed miRNAs and explored the possibility as potential biomarkers for early-onset OMG. METHODS Peripheral blood samples were collected from patients with early-onset OMG, early-onset GMG, and age-matched healthy subjects, with 6 samples in each group. All these patients were diagnosed as MG for the first time and did not undergo any treatment. Exosomes miRNAs were extracted from the serum and performed deep sequencing; the differentially expressed miRNAs were compared and analyzed between OMG, GMG, and healthy control groups using edgeR. The differential expression standard was set to | log2FC |>1, p < 0.05. Target prediction of mRNAs were performed using miRTarBase, TargetScan, and miRDB databases, and a protein-protein interaction (PPI) network was constructed subsequently. The miRNAs with a significant difference were validated using RT-qPCR (10 early-onset OMG patients, 10 early-onset GMG patients and 10 age-sex-matched healthy subjects), and the value of the area under the ROC curve (AUC) was used to assess the diagnostic accuracy and evaluate clinical prognostic value. RESULTS In total, one upregulated (miR-130a-3p) miRNA was obtained through the upregulated intersection between control vs OMG and OMG vs GMG; four downregulated (miR-4712-3p; miR-6752-5p; miR-320d; miR-3614-3p) miRNAs were obtained through the downregulated intersection between control vs OMG and OMG vs GMG. A total of 408 target genes were predicted for the five differentially expressed miRNAs. The mTOR signaling pathway and Rap1 signaling pathway were significantly enriched based on the enrichment results. RT-qPCR findings revealed that for the OMG, the expression of miR-320d, miR-4712-3p and miR-3614-3p was markedly up-/down-regulated as compared to GMG and healthy control group. The AUC for the three miRNAs between OMG and healthy control groups were 0.78, 0.79 and 0.79 respectively; the AUC between OMG and GMG was 0.84. CONCLUSIONS The present study identified three novel miRNAs as candidate biomarkers for early-onset OMG patients and it was expected to provide a possibility and a new orientation for serum exosomal miRNAs as OMG diagnostic biomarkers.
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Affiliation(s)
- Yajun Mu
- Department of Ophthalmology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xin Huang
- Department of Neurology, The First Affiliated Hospital of Sun Yat sen University, Guangzhou, China
| | - Yuanting Yang
- Department of Ophthalmology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Ziqing Huang
- Department of Ophthalmology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jiaxin Chen
- Department of Neurology, The First Affiliated Hospital of Sun Yat sen University, Guangzhou, China
| | - Shiyin Li
- Department of Neurology, The First Affiliated Hospital of Sun Yat sen University, Guangzhou, China
| | - Yuying Dong
- Department of Ophthalmology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Fangyuan Chen
- Department of Ophthalmology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Rijia Zhang
- Department of Ophthalmology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jian Chen
- Department of Ophthalmology, The First Affiliated Hospital of Jinan University, Guangzhou, China.
| | - Huiyu Feng
- Department of Neurology, The First Affiliated Hospital of Sun Yat sen University, Guangzhou, China.
| | - Qing Zhou
- Department of Ophthalmology, The First Affiliated Hospital of Jinan University, Guangzhou, China.
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Parthan A, Royston M, Thanataveerat A, East EL, Parzynski CS, Habib AA. Burden of illness and costs in patients with myasthenia gravis currently receiving treatment in the United States. Muscle Nerve 2024; 69:157-165. [PMID: 38018505 DOI: 10.1002/mus.27992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION/AIMS If myasthenia gravis (MG) symptoms are inadequately controlled, patients may experience exacerbations or life-threatening myasthenic crises. Patients with inadequately controlled MG symptoms tend to be treated with chronic intravenous immunoglobulin (IVIg) therapy and/or multiple immunosuppressant therapies (ISTs). This study aimed to examine disease burden, healthcare resource utilization, and associated costs in these patients. METHODS This was a retrospective observational study using a claims database. Patients with MG were classified into three cohorts based on treatment over a 1-y follow-up period: (a) treated with four or more IVIg episodes (chronic IVIg cohort); (b) received two or more non-steroidal ISTs (NSISTs) sequentially (multiple NSIST cohort); (c) received neither chronic IVIg nor multiple NSISTs (reference cohort). Incidences of crises and exacerbations and annual healthcare costs in each cohort were estimated. RESULTS In total, 3516 patients with MG were included in the analysis. Compared with the reference cohort (n = 2992), the MG crisis rate was approximately twice as high in both the chronic IVIg (n = 324) and multiple NSIST (n = 291) cohorts (p < 0.001); and the MG exacerbation rate was approximately four-fold higher in the chronic IVIg cohort (p < 0.001) and three-fold higher in the multiple NSIST cohort (p < 0.001). Median annual MG-related inflation-adjusted total healthcare costs were higher in the chronic IVIg ($81,900) and multiple NSIST ($30,300) cohorts than in the reference cohort ($2540). DISCUSSION The burden of crises/exacerbations was substantially higher and healthcare costs were considerably greater in patients with MG treated with chronic IVIg or multiple NSISTs than in patients not receiving these treatments.
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Affiliation(s)
- A Parthan
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - M Royston
- Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | | | - E L East
- Genesis Research Group, Hoboken, New Jersey, USA
| | | | - A A Habib
- University of California, Irvine, California, USA
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San PP, Jacob S. Role of complement in myasthenia gravis. Front Neurol 2023; 14:1277596. [PMID: 37869140 PMCID: PMC10585143 DOI: 10.3389/fneur.2023.1277596] [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: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
Myasthenia gravis is a prototypic neuroimmune disorder with autoantibodies targeting the acetylcholine receptor complex at the neuromuscular junction. Patients present with mainly ocular muscle weakness and tend to have a generalized muscle weakness later in the clinical course. The weakness can be severe and fatal when bulbar muscles are heavily involved. Acetylcholine receptor antibodies are present in the majority of patients and are of IgG1 and IgG3 subtypes which can activate the complement system. The complement involvement plays a major role in the neuromuscular junction damage and the supporting evidence in the literature is described in this article. Complement therapies were initially studied and approved for paroxysmal nocturnal hemoglobinuria and in the past decade, those have also been studied in myasthenia gravis. The currently available randomized control trial and real-world data on the efficacy and safety of the approved and investigational complement therapies are summarized in this review.
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Affiliation(s)
- Pyae Phyo San
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Saiju Jacob
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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Rituximab for myasthenia gravis. Cochrane Database Syst Rev 2023. [PMCID: PMC10075239 DOI: 10.1002/14651858.cd014574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess: the safety and efficacy, as assessed by the effect on disease severity or functional ability and the burden of alternative treatment, of rituximab (including biosimilar variants) for the treatment of myasthenia gravis in adults; and outcomes and adverse effects between different patient subgroups, and treatment strategies, in order to aid treatment choice for individuals, and to inform policymakers about those most likely to benefit.
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Behbehani R. Ocular Myasthenia Gravis: A Current Overview. Eye Brain 2023; 15:1-13. [PMID: 36778719 PMCID: PMC9911903 DOI: 10.2147/eb.s389629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
Ocular myasthenia gravis (OMG) is a neuromuscular disease characterized by autoantibody production against post-synaptic proteins in the neuromuscular junction. The pathophysiological auto-immune mechanisms of myasthenia are diverse, and this is governed primarily by the type of autoantibody production. The diagnosis of OMG relies mainly on clinical assessment, the use of serological antibody assays for acetylcholine receptors (AchR), muscle-specific tyrosine kinase (MusK), and low-density lipoprotein 4 (LPR4). Other autoantibodies against post-synaptic proteins, such as cortactin and agrin, have been detected; however, their diagnostic value and pathogenic effect are not yet clearly defined. Clinical tests such as the ice test and electrophysiologic tests, particularly single-fiber electromyography, have a valuable role in diagnosis. The treatment of OMG is primarily through cholinesterase inhibitors (pyridostigmine), and steroids are frequently required in cases of ophthalmoplegia. Other immunosuppressive therapies include antimetabolites (azathioprine, mycophenolate mofetil, methotrexate) and biological agents such as B-cell depleting agents (Rituximab) and complement inhibitors (eculizumab). Evidence is scarce on the effect of immunosuppressive therapy on altering the natural course of OMG. Clinicians must be vigilant of a myasthenic syndrome in patients using immune-check inhibitors. Reliable and consistent biomarkers are required to assess disease severity and response to therapy to optimize the management of OMG. The purpose of this review is to summarize the current trends and the latest developments in diagnosing and treating OMG.
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Affiliation(s)
- Raed Behbehani
- Neuroophthalmology Unit, Ibn Sina Hospital, Kuwait City, Kuwait,Correspondence: Raed Behbehani, Ibn Sina Hospital, P.O Box 1180, Tel +965 2224 2999, Fax +965 2249 2406, Email
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Epidemiology of myasthenia gravis in the province of Ourense (Galicia, Spain). NEUROLOGÍA (ENGLISH EDITION) 2022; 38:75-81. [PMID: 35249845 DOI: 10.1016/j.nrleng.2020.06.013] [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: 11/06/2019] [Accepted: 06/12/2020] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune disease affecting nerve transmission at the level of the neuromuscular junction, and typically causes fluctuating muscle weakness. Epidemiological studies show an increase in MG prevalence, particularly among the older population. OBJECTIVE We performed a retrospective epidemiological study to determine the incidence and prevalence of MG in the province of Ourense (Galicia, Spain), characterised by population ageing. MATERIAL AND METHODS Patients were selected from our clinical neuromuscular diseases database by searching for patients with an active prescription for pyridostigmine bromide. Incidence was estimated for the period 2009-2018. We calculated prevalence at 31/12/2018. According to census data for the province of Ourense, the population on 1/1/2019 was 307 651, of whom 96 544 (31.4%) were aged ≥ 65 years. RESULTS We identified 80 cases of MG, with a prevalence rate of 260 cases/1 000 000 population (95% CI, 202.7-316.4), rising to 517.9/1 000 000 population in those aged ≥ 65 (95% CI, 363.2-672.9). Cumulative incidence in the study period was 15.4 cases per 1 000 000 person-years. Early onset (≤ 50 years) was recorded in 29.1% of cases. CONCLUSION The prevalence of MG in our health district is one of the highest published figures, and the disease is highly prevalent in the older population.
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Salari N, Fatahi B, Bartina Y, Kazeminia M, Fatahian R, Mohammadi P, Shohaimi S, Mohammadi M. Global prevalence of myasthenia gravis and the effectiveness of common drugs in its treatment: a systematic review and meta-analysis. J Transl Med 2021; 19:516. [PMID: 34930325 PMCID: PMC8686543 DOI: 10.1186/s12967-021-03185-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Myasthenia gravis is a neuromuscular autoimmune disorder characterized by weakness and disability in the voluntary muscles. There have been several preliminary studies on the epidemiology of myasthenia gravis in different parts of the world and the effectiveness of common drugs in its treatment, but there has been no comprehensive study of the efficacy of common drugs in the treatment of myasthenia gravis. Therefore, this study aimed to determine the epidemiology of myasthenia gravis globally and the effectiveness of common drugs in its treatment using systematic review and meta-analysis. METHODS Research studies were extracted from IranDoc, MagIran, IranMedex, SID, ScienceDirect, Web of Sciences (WoS), ProQuest, Medline (PubMed), Scopus and Google Scholar based on Cochran's seven-step guidelines using existing keywords extracted in MeSH browser. The I2 test was used to calculate the heterogeneity of studies, and Begg and Mazumdar rank correlation tests were used to assess publication bias. Data were analyzed using Comprehensive Meta-Analysis software (Version 2). RESULTS In the search for descriptive studies based on the research question, 7374 articles were found. After deleting articles unrelated to the research question, finally, 63 articles with a sample size of 1,206,961,907 people were included in the meta-analysis. The prevalence of MG worldwide was estimated to be 12.4 people (95% CI 10.6-14.5) per 100,000 population. For analytical studies on the effectiveness of common myasthenia gravis drugs, 4672 articles were found initially, and after removing articles unrelated to the research question, finally, 20 articles with a sample size of 643 people in the drug group and 619 people in the placebo group were included in the study. As a result of the combination of studies, the difference between the mean QMGS score index after taking Mycophenolate and Immunoglobulin or plasma exchange drugs in the group of patients showed a significant decrease of 1.4 ± 0.77 and 0.62 ± 0.28, respectively (P < 0.01). CONCLUSION The results of systematic review of drug evaluation in patients with myasthenia gravis showed that Mycophenolate and Immunoglobulin or plasma exchange drugs have positive effects in the treatment of MG. It also represents the positive effect of immunoglobulin or plasma exchange on reducing SFEMG index and QMGS index and the positive effect of Mycophenolate in reducing MG-ADL index, SFEMG and Anti-AChR antibodies index. In addition, based on a meta-analysis of the random-effect model, the overall prevalence of MG in the world is 12.4 people per 100,000 population, which indicates the urgent need for attention to this disease for prevention and treatment.
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Affiliation(s)
- Nader Salari
- Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Behnaz Fatahi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Yalda Bartina
- Department of Translation Studies, Faculty of Literature, Istanbul University, Istanbul, Turkey
| | - Mohsen Kazeminia
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Fatahian
- Department of Neurosurgery, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Payam Mohammadi
- Department of Neurology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shamarina Shohaimi
- Department of Biology, Faculty of Science, University Putra Malaysia, Serdang, Selangor Malaysia
| | - Masoud Mohammadi
- Cellular and Molecular Research Center, Gerash University of Medical Sciences, Gerash, Iran
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Ursache von Muskelschwäche: Spektrum neuromuskulärer Erkrankungen und diagnostisches Vorgehen. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1548-8821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungDas Leitsymptom der muskulären Schwäche kann auf das Vorliegen einer neuromuskulären Erkrankung zurückzuführen sein, findet sich jedoch auch bei einer Reihe anderer Faktoren wie Elektrolytveränderungen, Vitaminmangel, Schilddrüsenerkrankungen, Bewegungsmangel oder bei unerwünschten Arzneimittelnebenwirkungen. Einer gründlichen Anamnese und körperlichen Untersuchung kommt daher in der differentialdiagnostischen Abklärung eine große Bedeutung zu. Die zeitliche Entwicklung, das Verteilungsmuster sowie Begleitsymptome erlauben oftmals bereits eine erste diagnostische Einordnung. Bei begründetem Verdacht auf das Vorliegen einer neuromuskulären Erkrankung sollte die weiterführende Diagnostik durch einen Neurologen oder ein neuromuskuläres Zentrum erfolgen. Zu den wichtigsten neuromuskulären Erkrankungen mit Leitsymptom einer muskulären Schwäche gehören die neuromuskulären Übertragungsstörungen, Neuropathien, erbliche und erworbene Myopathien sowie Motoneuronerkrankungen. Diese Übersicht stellt die wichtigsten Ursachen für eine muskuläre Schwäche zusammen und zeigt das zu empfehlende diagnostische Vorgehen auf.
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Development of a Computerized Adaptive Test for Quantifying Chinese Medicine Syndrome of Myasthenia Gravis on Basis of Multidimensional Item Response Theory. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2021. [PMID: 34122609 DOI: 10.1155/2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Making comprehensive management of myasthenia gravis (MG) is a challenge in clinical practice due to heterogeneity and multiple comorbidities among patients. AIM To develop an end-to-end instrument for individualized assessment of MG in the perspective of Chinese medicine (TCM) with the application of multidisciplinary quantification approaches. METHODS A self-administrated questionnaire was developed integrating typical symptoms of MG and spleen-kidney deficiency syndrome on basis of the conceptual framework of TCM. With data collected in a multicenter cross-sectional study, confirmatory factor analysis together with multidimensional item response theory (MIRT) was used for evaluating the psychometric property of the questionnaire. A computerized adaptive test was developed based on the MIRT model, and scores of syndrome factors were calculated in simulation. A logistics regression model was also estimated for evaluating the consistency between the quantitative result and the clinical diagnosis of syndrome from clinical practitioners. RESULT With 337 patients enrolled and assessed, the 14-item questionnaire was evaluated to be with adequate validity and reliability (Cronbach's alpha indices = 0.87, AIC = 195.827, BIC = 348.631, CFI = 0.921, RMR = 0.006, GFI = 0.954, RMSEA = 0.048, and χ2/df = 1.782). With adequate factor loadings of symptoms on related syndrome factor, the instrument was evaluated with preliminary interpretation and was suitable for evaluating patients with moderate severity of the spleen and kidney deficiency syndrome. CONCLUSION Setting typical symptoms of MG together with systemic discomforts in a computerized adaptive test on the basis of MIRT, this study proposed an innovative research paradigm for quantifying individual condition in the perspective of TCM with application of interdisciplinary approaches.
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Development of a Computerized Adaptive Test for Quantifying Chinese Medicine Syndrome of Myasthenia Gravis on Basis of Multidimensional Item Response Theory. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:9915503. [PMID: 34122609 PMCID: PMC8166489 DOI: 10.1155/2021/9915503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/29/2021] [Accepted: 04/03/2021] [Indexed: 11/30/2022]
Abstract
Background Making comprehensive management of myasthenia gravis (MG) is a challenge in clinical practice due to heterogeneity and multiple comorbidities among patients. Aim To develop an end-to-end instrument for individualized assessment of MG in the perspective of Chinese medicine (TCM) with the application of multidisciplinary quantification approaches. Methods A self-administrated questionnaire was developed integrating typical symptoms of MG and spleen-kidney deficiency syndrome on basis of the conceptual framework of TCM. With data collected in a multicenter cross-sectional study, confirmatory factor analysis together with multidimensional item response theory (MIRT) was used for evaluating the psychometric property of the questionnaire. A computerized adaptive test was developed based on the MIRT model, and scores of syndrome factors were calculated in simulation. A logistics regression model was also estimated for evaluating the consistency between the quantitative result and the clinical diagnosis of syndrome from clinical practitioners. Result With 337 patients enrolled and assessed, the 14-item questionnaire was evaluated to be with adequate validity and reliability (Cronbach's alpha indices = 0.87, AIC = 195.827, BIC = 348.631, CFI = 0.921, RMR = 0.006, GFI = 0.954, RMSEA = 0.048, and χ2/df = 1.782). With adequate factor loadings of symptoms on related syndrome factor, the instrument was evaluated with preliminary interpretation and was suitable for evaluating patients with moderate severity of the spleen and kidney deficiency syndrome. Conclusion Setting typical symptoms of MG together with systemic discomforts in a computerized adaptive test on the basis of MIRT, this study proposed an innovative research paradigm for quantifying individual condition in the perspective of TCM with application of interdisciplinary approaches.
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Alqarni F, Almalki D, Aljohani Z, Ali A, AlSaleem A, Alotaibi N, Odeh S, Dalbhi SA. Prevalence and risk factors of myasthenia gravis recurrence post-thymectomy. ACTA ACUST UNITED AC 2021; 26:4-14. [PMID: 33530037 PMCID: PMC8015504 DOI: 10.17712/nsj.2021.1.20190041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 08/30/2020] [Indexed: 12/13/2022]
Abstract
Objectives: To evaluate the prevalence and the factors associated with recurrence of myasthenia gravis following thymectomy. Methods: Six electronic databases which reported on recurrence of myasthenia gravis following thymectomy and/or its risk factors from 1985 to 2018 were searched. Summary prevalence and risk values obtained based on the random effect models were reported. Results: Seventy (70) papers containing 7,287 individuals with myasthenia gravis who received thymectomy as part of their management were retrieved. The patients had a mean follow-up of 4.65 years post-thymectomy. The prevalence of myasthenia gravis recurrence post-thymectomy was 18.0% (95% CI 14.7–22.0%; 1865/7287). Evident heterogeneity was observed (I2=93.6%; p<0.001). Recurrence rate was insignificantly higher in male compared with female patients (31.3 vs. 23.8%; p=0.104). Pooled recurrence rates for thymomatous (33.3%) was higher than the rate among non-thymomatous (20.8%) myasthenia gravis patients (Q=4.19, p=0.041). Risk factors for recurrence include older age, male sex, disease severity, having thymomatous myasthenia gravis, longer duration of the myasthenia gravis before surgery, and having an ectopic thymic tissue. Conclusion: A fifth of individuals with myasthenia gravis experience recurrence after thymectomy. Closer monitoring should be given to at-risk patients and further studies are needed to understand interventions to address these risks.
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Affiliation(s)
- Fatmah Alqarni
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Daifallah Almalki
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Ziyad Aljohani
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Abdulrahman Ali
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Alanood AlSaleem
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Noura Alotaibi
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Shahla Odeh
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Sultan Al Dalbhi
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
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Álvarez-Velasco R, Gutiérrez-Gutiérrez G, Trujillo JC, Martínez E, Segovia S, Arribas-Velasco M, Fernández G, Paradas C, Vélez-Gómez B, Casasnovas C, Nedkova V, Guerrero-Sola A, Ramos-Fransi A, Martínez-Piñeiro A, Pardo J, Sevilla T, Gómez-Caravaca MT, López de Munain A, Jericó I, Pelayo-Negro AL, Martín MA, Morgado Y, Mendoza MD, Pérez-Pérez H, Rojas-García R, Turon-Sans J, Querol L, Gallardo E, Illa I, Cortés-Vicente E. Clinical characteristics and outcomes of thymoma-associated myasthenia gravis. Eur J Neurol 2021; 28:2083-2091. [PMID: 33721382 DOI: 10.1111/ene.14820] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/26/2021] [Accepted: 03/10/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND PURPOSE Prognosis of myasthenia gravis (MG) in patients with thymoma is not well established. Moreover, it is not clear whether thymoma recurrence or unresectable lesions entail a worse prognosis of MG. METHODS This multicenter study was based on data from a Spanish neurologist-driven MG registry. All patients were aged >18 years at onset and had anti-acetylcholine receptor antibodies. We compared the clinical data of thymomatous and nonthymomatous patients. Prognosis of patients with recurrent or nonresectable thymomas was assessed. RESULTS We included 964 patients from 15 hospitals; 148 (15.4%) had thymoma-associated MG. Median follow-up time was 4.6 years. At onset, thymoma-associated MG patients were younger (52.0 vs. 60.4 years, p < 0.001), had more generalized symptoms (odds ratio [OR]: 3.02, 95% confidence interval [CI]: 1.95-4.68, p < 0.001) and more severe clinical forms according to the Myasthenia Gravis Foundation of America (MGFA) scale (OR: 1.6, 95% CI: 1.15-2.21, p = 0.005). Disease severity based on MGFA postintervention status (MGFA-PIS) was higher in thymomatous patients at 1 year, 5 years, and the end of follow-up. Treatment refractoriness and mortality were also higher (OR: 2.28, 95% CI: 1.43-3.63, p = 0.001; hazard ratio: 2.46, 95% CI: 1.47-4.14, p = 0.001). Myasthenic symptoms worsened in 13 of 27 patients with recurrences, but differences in long-term severity were not significant. Fifteen thymomatous patients had nonresectable thymomas with worse MGFA-PIS and higher mortality at the end of follow-up. CONCLUSIONS Thymoma-associated MG patients had more severe myasthenic symptoms and worse prognosis. Thymoma recurrence was frequently associated with transient worsening of MG, but long-term prognosis did not differ from nonrecurrent thymoma. Patients with nonresectable thymoma tended to present severe forms of MG.
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Affiliation(s)
- Rodrigo Álvarez-Velasco
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Gerardo Gutiérrez-Gutiérrez
- Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Spain
| | - Juan Carlos Trujillo
- Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain.,Department of Thoracic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Elisabeth Martínez
- Department of Thoracic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Sonia Segovia
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Marina Arribas-Velasco
- Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Spain
| | - Guillermo Fernández
- Department of Neurology, Hospital Universitario Infanta Sofía, Universidad Europea de Madrid, San Sebastián de los Reyes, Spain
| | - Carmen Paradas
- Neurology Department, Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla, Seville, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz Vélez-Gómez
- Neurology Department, Neuromuscular Disorders Unit, Instituto de Biomedicina de Sevilla, Hospital U. Virgen del Rocío, CSIC, Universidad de Sevilla, Seville, Spain
| | - Carlos Casasnovas
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain.,Neuromuscular Unit, Neurology Department, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.,Neurometabolic Diseases Group, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
| | - Velina Nedkova
- Neuromuscular Unit, Neurology Department, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Antonio Guerrero-Sola
- Neuromuscular Diseases and ALS Unit, Department of Neurology, Institute of Neurosciences, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Alba Ramos-Fransi
- Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain.,Neuromuscular Diseases Unit, Department of Neurology, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Alicia Martínez-Piñeiro
- Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain.,Neuromuscular Diseases Unit, Department of Neurology, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Julio Pardo
- Department of Neurology, Hospital Clínico de Santiago de Compostela, Santiago de Compostela, Spain
| | - Teresa Sevilla
- Neuromuscular Unit, Neurology Department, Hospital Universitari i Politècnic La Fe, Department of Medicine, Universitat de València, and Biomedical Research Institute La Fe (IIS La Fe), Valencia, Spain
| | | | - Adolfo López de Munain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain.,Neuromuscular Unit, Hospital Universitario de Donostia. Biodonostia Health Research Institute, University of the Basque Country, Gipuzkoa, Spain
| | - Ivonne Jericó
- Department of Neurology, Complejo Hospitalario de Navarra, IdisNa (Instituto Investigación Sanitaria Navarra), Pamplona, Spain
| | - Ana L Pelayo-Negro
- Department of Neurology, Hospital Universitario Marqués de Valdecilla, University of Cantabria, Santander, Spain
| | | | - Yolanda Morgado
- Department of Neurology, Hospital Universitario de Valme, Seville, Spain
| | - María Dolores Mendoza
- Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Helena Pérez-Pérez
- Department of Neurology, Complejo Hospitalario Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Ricard Rojas-García
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Janina Turon-Sans
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Eduard Gallardo
- Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Isabel Illa
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Cortés-Vicente
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Department of Medicine, Universitat Autónoma de Barcelona, Barcelona, Spain.,Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
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15
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Marshall B, Sharma U, Benes-Lima L, Rossi FH. Hemisensory loss in myasthenia gravis. BMJ Case Rep 2021; 14:e237405. [PMID: 33731400 PMCID: PMC7978066 DOI: 10.1136/bcr-2020-237405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 11/03/2022] Open
Abstract
A 73-year-old white man presents with left-sided ptosis and diplopia in the absence of ophthalmoplegia, with left hemibody paresthesia. He reports intermittent dysphagia and dizziness for 1 month and diarrhoea for 2 months. Serum and electrodiagnostic studies confirmed the diagnosis of myasthenia gravis. This case highlights the non-classic presentation of myasthenia gravis in the absence of ophthalmoplegia with a unique unexplained hemisensory deficit.
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Affiliation(s)
- Brandon Marshall
- University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Umesh Sharma
- Department of Neurology, Orlando Veterans Affairs Medical Center-Lake Nona, Orlando, Florida, USA
- Neurology, University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Lourdes Benes-Lima
- Department of Neurology, Orlando Veterans Affairs Medical Center-Lake Nona, Orlando, Florida, USA
- Neurology, University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Fabian H Rossi
- Department of Neurology, Orlando Veterans Affairs Medical Center-Lake Nona, Orlando, Florida, USA
- Neurology, University of Central Florida College of Medicine, Orlando, Florida, USA
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16
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Arias Chavez JF, Fernandez CJ. Myasthenia gravis presenting as bilateral pseudointernuclear ophthalmoplegia in a patient with an incidental prolactinoma. BMJ Case Rep 2020; 13:13/12/e234322. [PMID: 33334740 PMCID: PMC7747538 DOI: 10.1136/bcr-2020-234322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Myasthenia gravis (MG) is a rare and potentially dangerous autoimmune condition, which affects the acetylcholine receptors at the neuromuscular junction of skeletal muscle. MG's diverse symptomatology may readily masquerade as other neurological conditions, posing a diagnostic challenge to clinicians. We describe a 24-year old man who presented to the emergency department with a new onset internuclear ophthalmoplegia. After a series of investigations, we eventually arrived at a diagnosis of MG with pseudointernuclear ophthalmoplegia with an incidentally detected prolactinoma. We explore the literature regarding the pathophysiology of pseudointernuclear ophthalmoplegia, the link between prolactin and autoimmunity and the association between prolactinoma and MG.
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17
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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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18
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García Estévez DA, López Díaz LM, Pardo Parrado M, Pérez Lorenzo G, Sabbagh Casado NA, Ozaita Arteche G, Rodríguez Gómez D. Epidemiology of myasthenia gravis in the province of Ourense (Galicia, Spain). Neurologia 2020; 38:S0213-4853(20)30215-2. [PMID: 32900528 DOI: 10.1016/j.nrl.2020.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 05/24/2020] [Accepted: 06/12/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Myasthenia gravis (MG) is an autoimmune disease affecting nerve transmission at the level of the neuromuscular junction, and typically causes fluctuating muscle weakness. Epidemiological studies show an increase in MG prevalence, particularly among the older population. OBJECTIVE We performed a retrospective epidemiological study to determine the incidence and prevalence of MG in the province of Ourense (Galicia, Spain), characterised by population ageing. MATERIAL AND METHODS Patients were selected from our clinical neuromuscular diseases database by searching for patients with an active prescription for pyridostigmine bromide. Incidence was estimated for the period 2009-2018. We calculated prevalence at 31/12/2018. According to census data for the province of Ourense, the population on 1/1/2019 was 307,651, of whom 96,544 (31.4%) were aged ≥ 65 years. RESULTS We identified 80 cases of MG, with a prevalence rate of 260 cases/1 000 000 population (95% CI, 202.7-316.4), rising to 517.9/1 000 000 population in those aged ≥ 65 (95% CI, 363.2-672.9). Cumulative incidence in the study period was 15.4 cases per 1 000 000 person-years. Early onset (≤ 50 years) was recorded in 29.1% of cases. CONCLUSION The prevalence of MG in our health district is one of the highest published figures, and the disease is highly prevalent in the older population.
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Affiliation(s)
- D A García Estévez
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España.
| | - L M López Díaz
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
| | - M Pardo Parrado
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
| | - G Pérez Lorenzo
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
| | - N A Sabbagh Casado
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
| | - G Ozaita Arteche
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
| | - D Rodríguez Gómez
- Servicio de Neurología, Complejo Hospitalario Universitario de Ourense, Ourense, España
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19
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Mantegazza R, O'Brien FL, Yountz M, Howard JF. Consistent improvement with eculizumab across muscle groups in myasthenia gravis. Ann Clin Transl Neurol 2020; 7:1327-1339. [PMID: 32700461 PMCID: PMC7448154 DOI: 10.1002/acn3.51121] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/10/2020] [Accepted: 06/10/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess whether eculizumab, a terminal complement inhibitor, improves patient- and physician-reported outcomes (evaluated using the myasthenia gravis activities of daily living profile and the quantitative myasthenia gravis scale, respectively) in patients with refractory anti-acetylcholine receptor antibody-positive generalized myasthenia gravis across four domains, representing ocular, bulbar, respiratory, and limb/gross motor muscle groups. METHODS Patients with refractory anti-acetylcholine receptor antibody-positive generalized myasthenia gravis were randomized 1:1 to receive either placebo or eculizumab during the REGAIN study (NCT01997229). Patients who completed REGAIN were eligible to continue into the open-label extension trial (NCT02301624) for up to 4 years. The four domain scores of each of the myasthenia gravis activities of daily living profile and the quantitative myasthenia gravis scale recorded throughout REGAIN and through 130 weeks of the open-label extension were analyzed. RESULTS Of the 125 patients who participated in REGAIN, 117 enrolled in the open-label extension; 61 had received placebo and 56 had received eculizumab during REGAIN. Patients experienced rapid improvements in total scores and all four domain scores of both the myasthenia gravis activities of daily living profile and the quantitative myasthenia gravis scale with eculizumab treatment. These improvements were sustained through 130 weeks of the open-label extension. INTERPRETATION Eculizumab treatment elicits rapid and sustained improvements in muscle strength across ocular, bulbar, respiratory, and limb/gross motor muscle groups and in associated daily activities in patients with refractory anti-acetylcholine receptor antibody-positive generalized myasthenia gravis.
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Affiliation(s)
- Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases UnitFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | | | | | - James F. Howard
- Department of NeurologyUniversity of North CarolinaChapel HillNC
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20
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Abstract
Objectives: Myasthenia gravis (MG) may be refractory to traditional therapies. Quality of life (QOL) and disease burden in patients with refractory and nonrefractory MG were compared using Myasthenia Gravis Foundation of America MG Patient Registry data. Methods: Adults aged 18 years or older with MG diagnosed ≥2 years before enrollment were included. Participants with refractory MG had received ≥2 previous and 1 current MG treatment and had MG Activities of Daily Living Scale total score ≥6 at enrollment; other participants had nonrefractory MG. MG QOL 15-item scale (MG-QOL15) scores were compared. Results: In total, 56 participants with refractory and 717 participants with nonrefractory MG enrolled. Participants with refractory MG had significantly higher mean (SD) MG-QOL15 total scores [31.4 (11.1) vs. 20.8 (15.0), P < 0.0001] and were more likely to have had exacerbations, emergency department visits, and recent hospitalizations. Conclusions: Participants with refractory MG experience worse QOL and greater clinical burden than those with nonrefractory disease.
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21
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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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22
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Harris L, Graham S, MacLachlan S, Exuzides A, Jacob S. Healthcare resource utilization by patients with treatment-refractory myasthenia gravis in England. J Med Econ 2019; 22:691-697. [PMID: 30841772 DOI: 10.1080/13696998.2019.1592180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Aims: To examine healthcare resource utilization associated with refractory myasthenia gravis (MG) in England. Materials and methods: This was a retrospective cohort study of linked data from the Clinical Practice Research Datalink and the Hospital Episode Statistics database collected between 1997 and 2016. Included patients were ≥18 years of age at the index MG diagnosis. Patients with refractory MG were identified using an algorithm based on treatments received. Healthcare resource utilization since the index date was compared between refractory and non-refractory cohorts. Results: The study included 1149 patients with MG, of whom 66 (5.7%) were refractory. Sex and age at diagnosis did not significantly differ between the refractory and non-refractory cohorts. Rates of healthcare resource utilization per person-year were significantly higher (p < .05) for patients with refractory compared to non-refractory MG for GP visits, visits to other healthcare professionals, outpatient visits and inpatient hospitalization. Patients in the refractory cohort spent more total days hospitalized since the index visit than patients in the non-refractory cohort (median, 33 vs. 16 days [p < .0001]). Limitations: The algorithm for identifying refractory patients did not include clinical criteria. Also, treatments administered in hospitals or by specialists were not available in the databases. Conclusions: Patients in England with refractory MG more often visit healthcare providers, are hospitalized and visit an emergency room than patients with non-refractory MG.
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Affiliation(s)
| | | | | | | | - Saiju Jacob
- d University Hospitals Birmingham , Birmingham , UK
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23
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Xin H, Harris LA, Aban IB, Cutter G. Examining the Impact of Refractory Myasthenia Gravis on Healthcare Resource Utilization in the United States: Analysis of a Myasthenia Gravis Foundation of America Patient Registry Sample. J Clin Neurol 2019; 15:376-385. [PMID: 31286711 PMCID: PMC6620464 DOI: 10.3988/jcn.2019.15.3.376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose Patients with refractory myasthenia gravis (MG) experience ongoing disease burden that might be reflected in their healthcare utilization. Here we examine the impact of refractory MG on healthcare utilization. Methods The 825 included participants were aged 18–64 years, enrolled in the Myasthenia Gravis Foundation of America Patient Registry between July 2013 and February 2018, and had been diagnosed with MG ≥2 years previously. Results Participants comprised 76 (9.2%) with refractory MG and 749 (90.8%) with nonrefractory MG. During the 6 months before enrollment, participants with refractory MG were significantly more likely than those with nonrefractory MG to have experienced at least one exacerbation [67.1% vs. 52.0%, respectively, p=0.01; odds ratio (OR)=1.882, 95% confidence interval (CI)=1.141–3.104], visited an emergency room at least once [43.4% vs. 27.1%, p<0.01; OR=2.065, 95% CI=1.276–3.343], been hospitalized overnight at least once (32.9% vs. 20.5%, p=0.01; OR=1.900, 95% CI=1.140–3.165), ever been admitted to an intensive care unit (ICU) (61.8% vs. 33.4%, p<0.01; OR=3.233, 95% CI=1.985–5.266), or ever required a feeding tube (21.1% vs. 9.1%, p<0.01; OR=2.671, 95% CI=1.457–4.896). A total of 75.8% younger females with refractory disease (<51 years, n=33) experienced at least one exacerbation, 69.7% had been admitted to an ICU, and 30.3% had required a feeding tube. For older females with refractory disease (≥51 years, n=33), 60.6%, 54.6%, and 6.1% experienced these outcomes, respectively (between-group differences were not significant). Conclusions Refractory MG is associated with higher disease burden and healthcare utilization than nonrefractory MG.
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Affiliation(s)
- Haichang Xin
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Inmaculada B Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
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24
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Fan L, Ma S, Yang Y, Yan Z, Li J, Li Z. Clinical differences of early and late-onset myasthenia gravis in 985 patients. Neurol Res 2018; 41:45-51. [PMID: 30311866 DOI: 10.1080/01616412.2018.1525121] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Lingling Fan
- Department of Neurology, The First Affiliated Hospital of Xi’an Medical University, Xi’an, China
| | - Shan Ma
- Department of Neurology, The First Affiliated Hospital of Xi’an Medical University, Xi’an, China
| | - Yongxiang Yang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
- Department of Neurosurgery, PLA 422nd Hospital, Zhanjiang, China
| | - Zhongjun Yan
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Junchao Li
- Department of Neurology, The First Affiliated Hospital of Xi’an Medical University, Xi’an, China
| | - Zhuyi Li
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
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25
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Cea G, Martinez D, Salinas R, Vidal C, Hoffmeister L, Stuardo A. Clinical and epidemiological features of myasthenia gravis in Chilean population. Acta Neurol Scand 2018; 138:338-343. [PMID: 29845611 DOI: 10.1111/ane.12967] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To provide an estimated prevalence and describe the clinical features of myasthenia gravis (MG) in Chile. METHOD We carried out (i) a prevalence study of MG using the capture-recapture method and the hospital register of pyridostigmine prescription in South-East Santiago (ii) a nationwide survey of MG patients. RESULTS Prevalence in adults in South-East Santiago was estimated to be 8.36/100 000 inhabitants (CI: 95%, 7.98-8.80). From the nationwide survey, 405 questionnaires were analysed, there was a female/male ratio of 2.2:1. The mean age of onset of symptoms was 38.7 years (range 1-89). The onset was ocular in 46.4%, oculobulbar in 11.6%, bulbar in 8.9%, limbs in 11.6% and generalized in 21.4%. Of the 13.3% of patients who had had a diagnosis of thymoma, only four of these patients were >60 years old at onset. Thymomas were commoner in patients living in mining counties. Patients ≥60 years old at onset of MG formed 19.5% of the sample, female/male ratio 0.97:1. Associated autoimmune diseases were reported in 14% of patients and in family members of 31.8% of patients. A total of 78 patients had to change work due to MG and 68 needed help in carrying out daily activities. CONCLUSIONS This study reduces the gap in information about MG in South America. The prevalence of MG in Chile is within the range described worldwide. We did not see an increase in male frequency in the older age of onset group and thymoma was more frequent in the fifth and sixth decades.
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Affiliation(s)
- G. Cea
- Facultad de Medicina; Departamento de Ciencias Neurológicas; Universidad de Chile; Santiago Chile
- Servicio de Neurología; Hospital del Salvador; Santiago Chile
| | | | - R. Salinas
- Facultad de Medicina; Departamento de Ciencias Neurológicas; Universidad de Chile; Santiago Chile
- Servicio de Neurología; Hospital del Salvador; Santiago Chile
| | - C. Vidal
- Escuela de Salud Pública; Universidad Mayor; Santiago Chile
| | - L. Hoffmeister
- Escuela de Salud Pública; Universidad Mayor; Santiago Chile
| | - A. Stuardo
- Servicio de Neurología; Hospital del Salvador; Santiago Chile
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26
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Cataneo AJM, Felisberto Jr. G, Cataneo DC. Thymectomy in nonthymomatous myasthenia gravis - systematic review and meta-analysis. Orphanet J Rare Dis 2018; 13:99. [PMID: 29940999 PMCID: PMC6020196 DOI: 10.1186/s13023-018-0837-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 06/05/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The objective of this study is to evaluate by means of a systematic review, the efficacy of thymectomy as compared to medical treatment for non-thymomatous myasthenia gravis (MG). METHODS Medline, Embase, and Lilacs were searched for experimental and observational studies that compared non-surgical (drug therapy) and surgical treatment of non-thymomatous MG (thymectomy performed by the transsternal approach). Inclusion criteria were: studies that compared the two types of treatment and had at least 10 adult patients in each group. Exclusion criteria were articles published before 1970, as well as those that included patients treated before 1950. The outcomes evaluated were: remission, and improvement rates. RevMan 5.3 software provided by the Cochrane Collaboration was used. When the heterogeneity between the studies was greater than 75%, a meta-analysis was not performed according to RevMan guidelines. RESULTS The total number of patients evaluated in 19 articles selected was 5841 (2911 surgical and 2930 non-surgical). Two included randomized clinical trials showed superiority of the surgical treatment over the non-surgical. Four retrospective studies with 379 patients paired by gender, age, and other confounders, also showed superiority of surgical treatment (OR 4.10, 95% CI 2.25 to 7.44; I2 = 20%). In meta-analyses, remission assessed in 17 studies (5686 patients) was greater in patients who underwent surgical treatment (OR 2.34, 95% CI 1.79 to 3.05; I2 = 56%). For improvement assessed in 13 studies (3063 patients) were not appropriate to carry out the meta-analysis due to the high heterogeneity among the studies in the outcome (87%). CONCLUSION Thymectomy may be considered effective in the treatment for non-thymomatous MG, with remission rate higher than for non-surgical treatment.
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Affiliation(s)
- Antônio J. M. Cataneo
- Division of Thoracic Surgery, Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, Botucatu, SP CEP 18.618-970 Brazil
| | - Gilmar Felisberto Jr.
- Post-Graduation Program General Bases of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, São Paulo, Brazil
| | - Daniele C. Cataneo
- Division of Thoracic Surgery, Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, Botucatu, SP CEP 18.618-970 Brazil
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27
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El-Sayed Mojahed M, Thabet EM, El-Khateeb MG, Elsayed Morgan A. Ocular vestibular evoked myogenic potential in patients with myasthenia gravis: A prospective clinical study. Auris Nasus Larynx 2018; 45:407-411. [PMID: 28662779 DOI: 10.1016/j.anl.2017.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/09/2017] [Accepted: 06/06/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Myasthenia gravis (MG) is an archetypic disorder of neuromuscular junctions (NMJs) and autoantibody-mediated disease causing fatigable weakness of skeletal muscles with an ocular onset in up to 85%. The aim of this study was to detect extra ocular muscles (EOMs) abnormalities in MG patients using ocular vestibular evoked myogenic potential (oVEMP) n10 response. METHODS The oVEMP was performed on 40 myasthenia gravis patients that were divided into three groups: newly diagnosed (10 patients), uncontrolled on treatment (15 patients) and controlled on treatment (15 patients) groups in addition to a control group of 10 subjects. Also a comparison of oVEMP response was held between patients with generalized and ocular MG. RESULTS The oVEMP n10 showed significant difference between the 3 study groups and the control. The n10 showed no significant difference between the newly diagnosed group and the other 2 groups. There was also significant difference between uncontrolled and controlled on treatment group and between generalized and ocular types of myasthenic patients. CONCLUSION The oVEMP can be usefully used in diagnosis of new MG patients as regard n10 amplitude, threshold and AR except n10 latency with no therapeutic or monitoring value of oVEMP in MG.
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28
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Lee I, Kaminski HJ, Xin H, Cutter G. Gender and quality of life in myasthenia gravis patients from the myasthenia gravis foundation of America registry. Muscle Nerve 2018; 58:90-98. [PMID: 29466829 DOI: 10.1002/mus.26104] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 02/12/2018] [Accepted: 02/17/2018] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Quality of life (QOL) has been poorly characterized among patients with myasthenia gravis (MG) other than assessments performed within the clinical setting. METHODS Patients age ≥ 18 years who were diagnosed with MG and registered with the MG patient registry between July 1, 2013, and June 30, 2016, were included. Demographic information, disease related history, and QOL were compared between men and women using multivariable analysis. RESULTS A total of 1,315 subjects (827 women) were included. Women were significantly younger, had a younger age at symptom onset, and were more likely to have thymoma and thymectomy. The 15-item Myasthenia Gravis Quality of Life scale (MG-QOL15) was significantly worse in women. MG-QOL15 score was comparable between women who had thymectomy and men with or without thymectomy. DISCUSSION QOL among MG patients is worse in women compared with men, but this disparity is eliminated in women who have undergone thymectomy. Muscle Nerve, 2018.
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Affiliation(s)
- Ikjae Lee
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Henry J Kaminski
- Department of Neurology, The George Washington University, Washington, DC, USA
| | - Haichang Xin
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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29
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Thomson DJ, Soni A, Ward M, Jones HW. Simultaneous Presentation of Myasthenia Gravis and Mesothelioma. J R Soc Med 2017; 99:259-60. [PMID: 16672761 PMCID: PMC1457761 DOI: 10.1177/014107680609900519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- D J Thomson
- Department of General Medicine, John Radcliffe Hospital, Oxford, UK
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30
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Sharma S, Malmeström C, Lindberg C, Meisel S, Schön K, Verolin M, Lycke NY. A Sensitive Method for Detecting Peptide-specific CD4 + T Cell Responses in Peripheral Blood from Patients with Myasthenia Gravis. Front Immunol 2017; 8:1370. [PMID: 29114250 PMCID: PMC5660702 DOI: 10.3389/fimmu.2017.01370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 10/05/2017] [Indexed: 01/04/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neurological disorder typified by skeletal muscle fatigue and most often production of autoantibodies against the nicotinic acetylcholine receptor (AChR). The present study was undertaken to assess the extent of AChR-peptide recognition in MG patients using co-culturing (DC:TC) of autologous monocyte-derived dendritic cells (moDCs) and highly enriched CD4+ T cells from the blood as compared to the traditional whole peripheral blood mononuclear cell (PBMC) cultures. We found that the DC:TC cultures were highly superior to the PBMC cultures for detection of reactivity toward HLA-DQ/DR-restricted AChR-peptides. In fact, whereas DC:TC cultures identified recognition in all MG patients the PBMC cultures failed to detect responsiveness in around 40% of the patients. Furthermore, reactivity to multiple peptides was evident in DC:TC cultures, while PBMC cultures mostly exhibited reactivity to a single peptide. No healthy control (HC) CD4+ T cells responded to the peptides in either culture system. Interestingly, whereas spontaneous production of IFNγ and IL-17 was observed in the DC:TC cultures from MG patients, recall responses to peptides enhanced IL-10 production in 9/13 MG patients, while little increase in IFNγ and IL-17 was seen. HCs did not produce cytokines to peptide stimulations. We conclude that the DC: TC culture system is significantly more sensitive and better identifies the extent of responsiveness in MG patients to AChR-peptides than traditional PBMC cultures.
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Affiliation(s)
- Sapna Sharma
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Clas Malmeström
- Laboratory for Clinical Immunology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Sarah Meisel
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Karin Schön
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Nils Yngve Lycke
- Department of Microbiology and Immunology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
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31
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Liu FC, Kuo CF, See LC, Tsai HI, Yu HP. Familial aggregation of myasthenia gravis in affected families: a population-based study. Clin Epidemiol 2017; 9:527-535. [PMID: 29138598 PMCID: PMC5679568 DOI: 10.2147/clep.s146617] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Introduction Myasthenia gravis (MG) is clinically heterogeneous and can be life-threatening if bulbar or respiratory muscles are involved. However, relative contributions of genetic, shared, and nonshared environmental factors to MG susceptibility remain unclear. The aim of this study was to examine the familial aggregation and heritability of MG and the relative risks (RRs) of other autoimmune diseases in the relatives of patients with MG. Methods A population-based family study using the Taiwan National Health Insurance (NHI) Database was conducted. Participants included all individuals (N=23,422,955) who were actively registered in the NHI Database in 2013, 15,066 of whom had at least one first-degree relative with MG. We identified 8,638 parent–child relationships, 3,279 with an affected offspring, 3,134 with affected siblings, and 26 with affected twins. Prevalence and RRs of MG and other autoimmune diseases in the relatives of patients as well as the relative contributions of heritability, shared, and nonshared environmental factors to MG susceptibility were measured. Results RRs (95% confidence intervals [CIs]) for MG were 17.85 (8.71–36.56) for patients’ siblings, 5.33 (2.79–10.18) for parents, 5.82 (3.03–11.16) for offspring, and 1.42 (0.20–10.10) for spouses without genetic similarities. RRs (95% CIs) in individuals with a first-degree relative with MG were 2.18 (1.53–3.12) for systemic lupus erythematosus, 1.73 (1.09–2.74) for primary Sjögren’s syndrome, 1.90 (1.66–2.18) for autoimmune thyroid disease, and 1.68 (1.22–2.30) for rheumatoid arthritis. Accountability for the phenotypic variance of MG was 82.1% for familial transmission and 17.9% for nonshared environmental factors. Conclusion Individual risks of MG and other autoimmune diseases are increased in the relatives of patients with MG. Familial transmission of MG was estimated to be 82.1%.
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Affiliation(s)
- Fu-Chao Liu
- Department of Anesthesiology, Chang Gung Memorial Hospital.,College of Medicine, Chang Gung University
| | - Chang-Fu Kuo
- College of Medicine, Chang Gung University.,Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital.,Department of Public Health, College of Medicine, Chang Gung University.,Office for Big Data Research, Chang Gung Memorial Hospital
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University.,Biostatistics Core Laboratory, Molecular Medicine Research Center
| | - Hsin-I Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital.,College of Medicine, Chang Gung University.,Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Huang-Ping Yu
- Department of Anesthesiology, Chang Gung Memorial Hospital.,College of Medicine, Chang Gung University
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32
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Duarte S, Santos E, Martins J, Martins Silva A, Lopes C, Gonçalves G, Leite MI. Myasthenia gravis with systemic and neurological polyautoimmunity. J Neurol Sci 2017; 381:39-40. [PMID: 28991712 DOI: 10.1016/j.jns.2017.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/07/2017] [Accepted: 08/08/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Sara Duarte
- Department of Neurology, Hospital de Santo António, Centro Hospitalar do Porto, Portugal.
| | - Ernestina Santos
- Department of Neurology, Hospital de Santo António, Centro Hospitalar do Porto, Portugal; Unit for Multidisciplinary Research in Biomedicine, ICBAS, University of Porto, Portugal
| | - Joana Martins
- Department of Neurology, Hospital de Santo António, Centro Hospitalar do Porto, Portugal
| | - Ana Martins Silva
- Department of Neurology, Hospital de Santo António, Centro Hospitalar do Porto, Portugal; Unit for Multidisciplinary Research in Biomedicine, ICBAS, University of Porto, Portugal
| | - Carlos Lopes
- Unit for Multidisciplinary Research in Biomedicine, ICBAS, University of Porto, Portugal
| | - Guilherme Gonçalves
- Unit for Multidisciplinary Research in Biomedicine, ICBAS, University of Porto, Portugal
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33
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Sehgal S, Rebello R, Wolmarans L, Elston M. Hickam's dictum: Myasthenia Gravis presenting concurrently with Graves' disease. BMJ Case Rep 2017; 2017:bcr-2017-220153. [PMID: 28882932 DOI: 10.1136/bcr-2017-220153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present two patients with Graves' disease and concurrent myasthenia gravis. The impact of the dual diagnosis on the clinical course and the potential for a delayed diagnosis of myasthenia gravis is discussed. Patient 1, a 28-year-old man was diagnosed with Graves' disease following his second respiratory arrest. His history was strongly suggestive of a second pathology. Patient 2, a 66-year-old Cantonese woman with established Graves' disease presented with thionamide-related neutropaenia. Examination revealed bilateral ptosis and right lateral rectus palsy. Both patients had thyrotoxicosis secondary to Graves' disease with concurrent myasthenia gravis. Although neuromuscular weakness is common in Graves' disease, coexisting myasthenia gravis (MG) is rare and can cause profound morbidity. Ocular signs in both diseases may cause diagnostic confusion although ptosis suggests coexisting MG. In both cases, the thyrotoxicosis delayed the diagnosis of MG.
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Affiliation(s)
- Shekhar Sehgal
- Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand
| | - Roshan Rebello
- Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand
| | - Louise Wolmarans
- Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand
| | - Marianne Elston
- Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand.,Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand
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34
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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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35
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HLA and age of onset in myasthenia gravis. Neuromuscul Disord 2017; 27:650-654. [DOI: 10.1016/j.nmd.2017.04.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/09/2017] [Accepted: 04/04/2017] [Indexed: 12/13/2022]
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36
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Ogawa Y, Nakagawa M, Yoshida T, Yazaki M, Sekijima Y, Hashimoto T, Ikeda S. Survey of epidemiology, clinical picture and current treatments for elderly‐onset (≥ 65 years) patients with myasthenia gravis in Nagano Prefecture, Japan. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/ncn3.12129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yuka Ogawa
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
| | - Michitaka Nakagawa
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
| | - Takuhiro Yoshida
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
| | - Masahide Yazaki
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
| | | | - Shu‐ichi Ikeda
- Department of Medicine (Neurology and Rheumatology) Shinshu University School of Medicine Matsumoto Japan
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Abstract
Neuromuscular disorders as a group are linked by anatomy with significant differences in pathogenetic mechanisms, clinical expression, and time course of disease. Each neuromuscular disease is relatively uncommon, yet causes a significant burden of disease socioeconomically. Epidemiologic studies in different global regions have demonstrated certain neuromuscular diseases have increased incidence and prevalence rates over time. Understanding differences in global epidemiologic trends will aid clinical research and policies focused on prevention of disease. There is a critical need to understand the global impact of neuromuscular diseases using metrics currently established for communicable and noncommunicable diseases.
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Affiliation(s)
- Jaydeep M Bhatt
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY 10016, USA.
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Effect of ethnic origin and gender on the clinical manifestations of myasthenia gravis among the Jewish population in Israel. J Neuroimmunol 2017; 307:47-52. [DOI: 10.1016/j.jneuroim.2017.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/04/2017] [Accepted: 04/05/2017] [Indexed: 11/24/2022]
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Morren JA, Levin KH, Shields RW. Diagnostic Accuracy of Single Fiber Electromyography for Myasthenia Gravis in Patients Followed Longitudinally. J Clin Neurophysiol 2017; 33:469-474. [PMID: 27749461 DOI: 10.1097/wnp.0000000000000285] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The literature lacks data on accuracy of single fiber electromyography (SFEMG) for myasthenia gravis (MG) patients followed longitudinally. METHODS We included patients with a clinical suspicion of MG who received SFEMG and follow-up at our institution between 2003 and 2013. Data collected included demographics, symptom details, clinical deficits, other diagnostic testing results, MG medication regimen, duration on treatment, response to therapy, and ultimate diagnosis after follow-up. When available, information was also extracted from the MG-specific Activities of Daily Living, MG Quality of Life, and European Quality of Life assessments before and after SFEMG. RESULTS Three hundred forty eight SFEMG patients met inclusion criteria. Myasthenia gravis was ultimately diagnosed in 31% (19% ocular, 12% generalized). A sensitivity of 78% was seen for MG regardless of subtype, 73% for ocular MG, and 85% for generalized MG. A specificity of 91% was obtained for MG of either ocular or generalized subtype. CONCLUSIONS The diagnostic accuracy of SFEMG using this methodology minimizing incorporation bias is more reliable than that usually described in previous studies. There is utility in increasing diagnostic yield when SFEMG results are combined with clinical data and those from other diagnostic tests, particularly serology.
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Affiliation(s)
- John A Morren
- *Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.; and †Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
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Aragonès J, Altimiras J, Roura P, Alonso F, Bufill E, Munmany A, Alfonso S, Illa I. Prevalence of myasthenia gravis in the Catalan county of Osona. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2014.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Comparison of Conservative Treatment and Thymectomy on Myasthenia Gravis Outcome. Ann Thorac Surg 2016; 102:1805-1813. [DOI: 10.1016/j.athoracsur.2016.08.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/13/2016] [Accepted: 08/09/2016] [Indexed: 11/19/2022]
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Boldingh MI, Maniaol AH, Brunborg C, Weedon-Fekjær H, Verschuuren JJGM, Tallaksen CME. Increased risk for clinical onset of myasthenia gravis during the postpartum period. Neurology 2016; 87:2139-2145. [PMID: 27770065 DOI: 10.1212/wnl.0000000000003339] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/03/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To study the risk of clinical onset of myasthenia gravis (MG) in pregnancy and during the first 6 months postpartum because an association between pregnancy or the postpartum period and the onset of autoimmune MG is widely assumed but not proven. METHODS The design was a cross-sectional population-based cohort study of 2 MG cohorts (Norway and the Netherlands) with 1,038 healthy controls from Norway. Data were obtained on 246 women with MG (age at onset 15-45 years). Data on pregnancy, hormonal factors, and clinical symptoms were collected by a previously validated environmental MG questionnaire. Relative risk of MG onset before, during, and after pregnancy was calculated by multinomial logistic regression for Norwegian women reaching 45 years of age, adjusted for the observed distribution of person-years in the corresponding control group. RESULTS Of the included women with MG, 13 (11.5%) of the Dutch and 24 (18.0%) of the Norwegian patients had their first myasthenia symptoms during the pregnancy or postpartum period. The postpartum period was confirmed to be significantly associated with the onset of symptoms of MG in Norwegian women with MG (relative risk 5.5, 95% confidence interval 2.6-11.6). The risk was highest after the first childbirth. CONCLUSIONS Women have a high-risk period for the onset of clinical symptoms of MG in the postpartum period, in particular after the first childbirth. Future studies should aim at elucidating the role of the hormonal-immunological-genetic interaction in the pathogenesis of MG.
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Affiliation(s)
- Marion I Boldingh
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway.
| | - Angelina H Maniaol
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway
| | - Cathrine Brunborg
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway
| | - Harald Weedon-Fekjær
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway
| | - Jan J G M Verschuuren
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway
| | - Chantal M E Tallaksen
- From the Department of Neurology (M.I.B., A.H.M., C.M.E.T.) and Oslo Centre for Biostatistics and Epidemiology (C.B., H.W.-F.), Research Support Services, Oslo University Hospital, Norway; Department of Neurology (J.J.G.M.V.), Leiden University Medical Centre, the Netherlands; and Institute of Clinical Medicine (M.I.B., C.M.E.T.), University of Oslo, Norway
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Khedr EM, Fawi G, Abbas MAA, Abo El-Fetoh N, Zaki AF, Gamea A, Al Attar G. Prevalence of neuromuscular disorders in Qena governorate/Egypt: population-based survey. Neurol Res 2016; 38:1056-1063. [DOI: 10.1080/01616412.2016.1243640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Eman M. Khedr
- Faculty of Medicine, Department of Neuropsychiatry, Assiut University, Assiut, Egypt
| | - Gharib Fawi
- Faculty of Medicine, Department of Neuropsychiatry, Sohag University, Sohag, Egypt
| | | | - Noha Abo El-Fetoh
- Faculty of Medicine, Department of Neuropsychiatry, Assiut University, Assiut, Egypt
| | - Ahmed F. Zaki
- Faculty of Medicine, Department of Neuropsychiatry, South Valley University, Qena, Egypt
| | - Ayman Gamea
- Faculty of Medicine, Department of Neuropsychiatry, South Valley University, Qena, Egypt
| | - Ghada Al Attar
- Faculty of Medicine, Department of Public Health and Community Medicine, Assiut University, Assiut, Egypt
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Melzer N, Ruck T, Fuhr P, Gold R, Hohlfeld R, Marx A, Melms A, Tackenberg B, Schalke B, Schneider-Gold C, Zimprich F, Meuth SG, Wiendl H. Clinical features, pathogenesis, and treatment of myasthenia gravis: a supplement to the Guidelines of the German Neurological Society. J Neurol 2016; 263:1473-94. [PMID: 26886206 PMCID: PMC4971048 DOI: 10.1007/s00415-016-8045-z] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 01/20/2016] [Accepted: 01/21/2016] [Indexed: 01/20/2023]
Abstract
Myasthenia gravis (MG) is an autoimmune antibody-mediated disorder of neuromuscular synaptic transmission. The clinical hallmark of MG consists of fluctuating fatigability and weakness affecting ocular, bulbar and (proximal) limb skeletal muscle groups. MG may either occur as an autoimmune disease with distinct immunogenetic characteristics or as a paraneoplastic syndrome associated with tumors of the thymus. Impairment of central thymic and peripheral self-tolerance mechanisms in both cases is thought to favor an autoimmune CD4(+) T cell-mediated B cell activation and synthesis of pathogenic high-affinity autoantibodies of either the IgG1 and 3 or IgG4 subclass. These autoantibodies bind to the nicotinic acetylcholine receptor (AchR) itself, or muscle-specific tyrosine-kinase (MuSK), lipoprotein receptor-related protein 4 (LRP4) and agrin involved in clustering of AchRs within the postsynaptic membrane and structural maintenance of the neuromuscular synapse. This results in disturbance of neuromuscular transmission and thus clinical manifestation of the disease. Emphasizing evidence from clinical trials, we provide an updated overview on immunopathogenesis, and derived current and future treatment strategies for MG divided into: (a) symptomatic treatments facilitating neuromuscular transmission, (b) antibody-depleting treatments, and
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Affiliation(s)
- Nico Melzer
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Tobias Ruck
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Peter Fuhr
- Department of Neurology, University of Basel, Basel, Switzerland
| | - Ralf Gold
- Department of Neurology, University of Bochum, Bochum, Germany
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexander Marx
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Arthur Melms
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Björn Tackenberg
- Department of Neurology, University of Marburg, Marburg, Germany
| | - Berthold Schalke
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | | | - Fritz Zimprich
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Sven G. Meuth
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Heinz Wiendl
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
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Santos E, Coutinho E, Moreira I, Silva AM, Lopes D, Costa H, Silveira F, Nadais G, Morais H, Martins J, Branco MC, Veiga A, Silva RS, Ferreira A, Sousa F, Freijo M, Matos I, André R, Negrão L, Fraga C, Santos M, Sampaio M, Lopes C, Leite MI, Gonçalves G. Epidemiology of myasthenia gravis in Northern Portugal: Frequency estimates and clinical epidemiological distribution of cases. Muscle Nerve 2016; 54:413-21. [PMID: 26851892 DOI: 10.1002/mus.25068] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/25/2016] [Accepted: 02/01/2016] [Indexed: 12/22/2022]
Abstract
INTRODUCTION In this study we estimated the prevalence, incidence, and mortality of myasthenia gravis (MG) in northern Portugal and characterized the clinical features of the patients identified. METHODS We used 2 data sources: clinical records from the hospitals and pyridostigmine prescription registers. RESULTS On December 31, 2013, we estimated a point prevalence of 111.7 patients per million population. The highest prevalence was observed in the group >65 years of age, especially in men (288.1 per million). During 2013, we estimated an incidence rate of 6.3 per million per year. Among women, the incidence rate was highest in the 15-49-year age group; in men, incidence increased with age up to 22.1 per million in those >65 years old. The MG-related mortality rate was 0.5 per million. CONCLUSIONS These figures are in keeping with similar studies and emphasize the importance of diagnosis and management of MG in elderly populations. Muscle Nerve 54: 413-421, 2016.
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Affiliation(s)
- Ernestina Santos
- Neurology Department, Hospital Santo Antonio, Centro Hospitalar Porto, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciencias Biomedicas de Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Ester Coutinho
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, University of Oxford, UK
| | - Isabel Moreira
- Neurology Department, Hospital Santo Antonio, Centro Hospitalar Porto, Porto, Portugal
| | - Ana Martins Silva
- Neurology Department, Hospital Santo Antonio, Centro Hospitalar Porto, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciencias Biomedicas de Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Dina Lopes
- Centro Hospitalar do Porto, Porto, Portugal
| | - Henrique Costa
- Neurology Department, Hospital Sao Joao, Porto, Portugal
| | | | - Goreti Nadais
- Neurology Department, Hospital Sao Joao, Porto, Portugal
| | - Hugo Morais
- Neurology Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Gaia, Portugal
| | - João Martins
- Neurology Department, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Maria Ceu Branco
- Neurology Department, Hospital Pedro Hispano, Matosinhos, Portugal.,Neurology Department, Hospital de Sao Pedro, Centro Hospitalar do Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Andreia Veiga
- Neurology Department, Hospital de Sao Pedro, Centro Hospitalar do Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Rosa Santos Silva
- Neurology Department, Centro Hospitalar do Alto Minho, Viana do Castelo, Portugal
| | - Augusto Ferreira
- Neurology Department, Centro Hospitalar Entre Douro e Vouga, Feira, Portugal
| | - Filipa Sousa
- Neurology Department, Hospital de Braga, Braga, Portugal
| | - Marta Freijo
- Neurology Department, Centro Hospitalar do Nordeste, Mirandela, Portugal
| | - Ilda Matos
- Neurology Department, Centro Hospitalar do Nordeste, Mirandela, Portugal
| | - Rui André
- Neurology Department, Hospital de São Teotonio, Viseu, Portugal
| | - Luís Negrão
- Neurology Department, Centro Hospitalar Universitario de Coimbra, Coimbra, Portugal
| | - Carla Fraga
- Neurology Department, Centro Hospitalar do Vale do Sousa, Penafiel, Portugal
| | - Manuela Santos
- Neuropediatrics Department, Centro Materno Infantil Norte, Centro Hospitalar Porto, Porto, Portugal
| | - Mafalda Sampaio
- Neuropediatrics Department, Hospital de Sao Joao, Porto, Portugal
| | - Carlos Lopes
- Instituto de Ciencias Biomedicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Maria Isabel Leite
- Nuffield Department of Clinical Neurosciences, Oxford University Hospitals, University of Oxford, UK
| | - Guilherme Gonçalves
- Unit for Multidisciplinary Research in Biomedicine, Instituto de Ciencias Biomedicas de Abel Salazar, Universidade do Porto, Porto, Portugal
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Benatar M, Mcdermott MP, Sanders DB, Wolfe GI, Barohn RJ, Nowak RJ, Hehir M, Juel V, Katzberg H, Tawil R. Efficacy of prednisone for the treatment of ocular myasthenia (EPITOME): A randomized, controlled trial. Muscle Nerve 2016; 53:363-9. [PMID: 26179124 PMCID: PMC6038933 DOI: 10.1002/mus.24769] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 11/12/2022]
Abstract
INTRODUCTION In this study we evaluated the safety, tolerability, and efficacy of prednisone in patients with ocular myasthenia gravis (OMG) concurrently treated with pyridostigmine. METHODS This investigation was a randomized, double-blind, placebo-controlled trial. Participants whose symptoms failed to remit on pyridostigmine were randomized to receive placebo or prednisone, initiated at 10 mg every other day, and titrated to a maximum of 40 mg/day over 16 weeks. The primary outcome measure was treatment failure. RESULTS Fewer subjects were randomized than the 88 planned. Of the 11 randomized, 9 completed 16 weeks of double-blind therapy. Treatment failure incidence was 100% (95% CI 48%-100%) in the placebo group (n = 5) vs. 17% (95% CI 0%-64%) in the prednisone group, P = 0.02 (n = 6). Median time to sustained minimal manifestation status (MMS) was 14 weeks, requiring an average prednisone dose of 15 mg/day. Adverse events were infrequent and generally mild in both groups. CONCLUSIONS A strategy of low-dose prednisone with gradual escalation appears to be safe, well-tolerated, and effective in treating OMG.
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Affiliation(s)
- Michael Benatar
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Michael P Mcdermott
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Donald B Sanders
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Gil I Wolfe
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Richard J Barohn
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Richard J Nowak
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Michael Hehir
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Vern Juel
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Hans Katzberg
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
| | - Rabi Tawil
- Department of Neurology, Miller School of Medicine, University of Miami, 1120 NW 14th Street, CRB 1318, Miami, Florida, 33136, USA
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Abstract
BACKGROUND Myasthenia gravis is an autoimmune disease of the neuromuscular junction, commonly affecting the ocular muscles. Cigarette smoking has been shown to influence many autoimmune diseases, including multiple sclerosis and rheumatoid arthritis, but its effect on myasthenia gravis has not been well studied. We sought to determine whether cigarette smoking influenced disease-related symptoms in ocular myasthenia gravis (OMG). METHODS We performed a prospective, clinic-based cross-sectional study in a single academic neuro-ophthalmology practice. All patients diagnosed with OMG between November 2006 and April 2014 were included. A prospective telephone survey was administered to determine smoking status and myasthenia gravis-related symptom severity. The main outcome measure was the myasthenia gravis-specific activities of daily living (MG-ADL) score, a well-validated marker of symptoms and quality of life in myasthenia gravis. RESULTS Forty-four patients were included in the analysis. Comparison of MG-ADL ocular subscores between current smokers (3.4 ± 2.6), former smokers (1.8 ± 2.1), and never smokers (1.1 ± 1.5) revealed a statistically significant relationship (P = 0.031) where current smokers had the highest MG-ADL ocular subscores and never smokers the lowest. Comparison of MG-ADL total scores revealed the same relationship (current 5.6 ± 4.5, former 2.9 ± 3.1, never 1.4 ± 2.5, P = 0.003). There were borderline significant correlations of pack years with MG-ADL ocular subscore (r = 0.27, P = 0.074) and MG-ADL total score (r = 0.30, P = 0.051). CONCLUSIONS Our findings indicate an association between cigarette smoking and symptom severity in OMG. This association suggests that smoking cessation in OMG patients may lead to improved symptom-related quality of life.
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Balarabe SA, Adamu MD, Watila MM, Jiya N. Neuromyelitis optica and myasthenia gravis in a young Nigerian girl. BMJ Case Rep 2015; 2015:bcr-2014-207362. [PMID: 26338241 DOI: 10.1136/bcr-2014-207362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Neuromyelitis optica (NMO) and myasthenia gravis (MG) are rare autoimmune disorders. The coexistence of the two disorders, although rare, has been documented. This is a case report of a 16-year-old student who presented with recurrent episodes of transverse myelitis and optic neuritis, 8 years after diagnosis of MG. She presented with visual impairment, relapsing and remitting weakness, numbness and paraesthesia of her lower limbs, with bladder and bowel incontinence. Her examination revealed bilateral optic atrophy, spastic paraparesis of the lower limbs and patchy sensory loss up to thoracic level (T4-5). She had a positive acetylcholine receptor antibody, a positive aquaporin-4 antibody and chest CT finding of thymic enlargement. We therefore confirmed the previous diagnosis of MG and performed a recent diagnosis of background NMO. A high index of suspicion is needed to make a diagnosis of this rare coexistence of NMO and MG in resource-limited settings such as Nigeria.
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Affiliation(s)
| | - Mohammad Dantani Adamu
- Department of Ophthalmology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Sokoto, Nigeria
| | - Musa Mamman Watila
- Department of Medicine, University of Maiduguri Teaching Hospital, Maiduguri, Borno, Nigeria
| | - Nma Jiya
- Department of Paediatrics, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Sokoto, Nigeria
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Mourão AM, Barbosa LSM, Comini-Frota ER, Freitas DDS, Gomez RS, Burns TM, Lemos SMA, Teixeira AL. Clinical profile of patients with myasthenia gravis followed at the University Hospital, Federal University of Minas Gerais. Rev Assoc Med Bras (1992) 2015; 61:156-60. [PMID: 26107366 DOI: 10.1590/1806-9282.61.02.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 10/21/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to determine the clinical profile of patients with myasthenia gravis (MG); followed at the Neuromuscular Diseases Clinic of the University Hospital, Federal University of Minas Gerais, Brazil, and to compare it with other Brazilian case series. METHODS sociodemographic and clinical data were collected from patients, and a systematic literature review performed, focusing on national studies on the clinical profile of MG patients. RESULTS sixty nine patients were enrolled in the study. Fifty five (91%) subjects were female and the mean age (SD) was 37.6 (± 11.4) years. The mean disease duration was 14.1 years. Regarding treatment, prednisone was the most used strategy (64%), followed by the use of azathioprine (43%). There was no difference between thymectomized (42) and non-thymectomized (27) patients regarding disease severity and medication use. CONCLUSION clinical and socio-demographic features of this MG sample from a University-based clinic resemble those reported in other Brazilian series and in the international literature.
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Affiliation(s)
| | | | | | - Denise da Silva Freitas
- Neurology Service, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Rodrigo Santiago Gomez
- Neurology Service, Clinics Hospital, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Ted M Burns
- University of Virginia, Charlottesville, Virginia, USA
| | - Stela Maris Aguiar Lemos
- Department of Speech Pathology and Audiology, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
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