Systemic lupus erythematosus-myasthenia gravis overlap syndrome: Presentation and treatment depend on prior thymectomy

In this study, we investigated four patients who met the diagnostic criteria for overlapping systemic lupus erythematosus (SLE) and myasthenia gravis (MG) but responded differently to treatment. All patients were acetylcholine receptor (AChR) and antinuclear antibody positive at the time of SLE diagnosis. Two patients presented with SLE who have been effectively treated with cholinesterase inhibitors for MG. These patients developed SLE with photosensitivity, rash, and arthritis post thymectomy, which had been performed 29 years and 40 years earlier, respectively. Two other patients were found to have AChR antibodies and MG in the context on new-onset SLE. These subjects were responsive to hydroxychloroquine and immunosuppression but failed cholinesterase inhibitors. The evolution of these cases is relevant for the role of thymus in lupus pathogenesis during aging and for treatment selection in SLE-MG overlap patients.

Intramuscular neostigmine and glycopyrrolate safely accelerated bowel evacuation in patients with spinal cord injury and defecatory disorders

Difficulty with evacuation after spinal cord injury (SCI) may be due to a lack of parasympathetic stimulation of the colon. Prior studies in persons with spinal cord injury have suggested that intravenous administration of neostigmine stimulates colonic motility while glycopyrrolate attenuates some of the cholinergic side effects of neostigmine. We thus performed a double-blind, cross-over study to evaluate the effect of neostigmine/glycopyrrolate injections in patients with SCI and defecatory difficulties. Seven subjects received active treatment (neostigmine 2 mg and glycopyrrolate 0.4 mg intramuscularly) during three consecutive bowel evacuation sessions and were crossed-over to placebo injections for three consecutive sessions. Compared with placebo, neostigmine/glycopyrrolate reduced the total bowel evacuation time from 98.1 +/- 7.2 to 74.8 min +/- 5.8 (p < 0.05). The lowest heart rate or blood pressure was not significantly different between the treatment and placebo groups. In conclusion, neostigmine/glycopyrrolate may improve bowel evacuation in patients with SCI-related defecatory disorders.

Anorectal stimulation causes increased colonic motor activity in subjects with spinal cord injury

BACKGROUND

Difficulty with evacuation (DWE) is a major problem after spinal cord injury (SCI). Stimulation of the anal canal and lower rectum, accomplished using a gloved finger (so-called digital rectal stimulation or DRS) is often used as an adjunct to laxatives and enemas to facilitate bowel evacuation. However, the basis for the efficacy of DRS is not known. This study assessed the effect of DRS on colonic motility.

METHODS

Six subjects with SCI were studied several hours after a bowel care session. Colonic motility was assessed using a manometric catheter (affixed endoscopically to the splenic flexure) at baseline, during DRS, and after DRS. In addition, evacuation of barium oatmeal paste (with the consistency of stool and introduced into the rectum and descending colon) was assessed simultaneously using fluoroscopic techniques.

RESULTS

The mean number (+/- SEM) of peristaltic waves per minute increased from 0 at baseline to 1.9 (+/- 0.5/min) during DRS and 1.5 (+/- 0.3/min) during the period immediately after cessation of DRS (P < 0.05). The mean amplitude (+/- SEM) of the peristaltic contractions was 43.4 (+/- 2.2) mmHg. The frequency of contractions, as well as amplitude of contractions, during or immediately after DRS was not significantly different. These manometric changes in response to DRS were accompanied by expulsion of barium oatmeal paste in every subject by the fifth DRS.

CONCLUSIONS

DRS causes left-sided colonic activity in subjects with SCI. At least in part, an anorectal colonic reflex that results in enhanced contractions of the descending colon and rectum may contribute to bowel evacuation in individuals with SCI.