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Peng S, Meng L, Fang R, Shen Q, Tian Y, Xiong A, Li S, Yang Y, Chang W, Ni J, Zhu W. Current state of research on exercise for the treatment of myasthenia gravis: A scoping review. Complement Ther Med 2024; 81:103033. [PMID: 38458542 DOI: 10.1016/j.ctim.2024.103033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/03/2024] [Accepted: 03/05/2024] [Indexed: 03/10/2024] Open
Abstract
OBJECTIVE To provide a comprehensive overview of existing evidence, research gaps, and future research priorities concerning the treatment of myasthenia gravis (MG) using exercise therapies. METHOD Clinical studies on exercise treatment for MG were searched in nine databases to conduct a scoping review. Two independent researchers screened the literature and comprehensively analyzed the characteristics and limitations of the included articles. RESULTS A total of 5725 studies were retrieved, of which 24 were included. The included studies were conducted in 16 different countries/regions and 456 patients were enrolled. Study designs included both interventional and observational studies. Exercise interventions included aerobic exercise, resistance exercise, balance training, and stretch training, and are typically administered in conjunction with medication, usual care, or some other interventions. The intensity, frequency, and duration of exercise interventions varied hugely among studies. Six-minute walk test, adverse events, muscle strength, MG quality of life-15 scale, forced vital capacity, quantitative MG scale, and MG activities of daily living scale were the most frequently used outcomes. All studies reported results in favor of the efficacy and safety of exercise in MG, and exercise-related adverse events were reported in two studies. CONCLUSION This scoping review provides an overview of the evidence concerning exercise treatment for MG. Key gaps in evidence include a limited number of participants, complex interventions, variability in outcome selection, and insufficient reporting in publications. The promotion of exercise treatment for MG still encounters several obstacles. A larger population, rigorous study design and conduction, standardized interventions and outcomes, and standardized reporting are essential.
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Affiliation(s)
- Siyang Peng
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Linghao Meng
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruiying Fang
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Qiqi Shen
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yukun Tian
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Anni Xiong
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Shaohong Li
- Treatment Center of Traditional Chinese Medicine, Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Yajing Yang
- Department of Traditional Chinese Medicine, Yuyuantan Community Health Center, Beijing, China
| | - Weiqian Chang
- Department of Acupuncture, Guang'anmen Hospital, Chinese Academy of Traditional Chinese Medicine Ji'nan Hospital (Ji'nan Hospital of Traditional Chinese Medicine), Shandong, China
| | - Jinxia Ni
- Department of Acupuncture, Dongzhimen Hospital of Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Wenzeng Zhu
- Department of Acupuncture, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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Engebretsen I, Gilhus NE, Kristiansen IS, Sæther EM, Lindberg-Schager I, Arneberg F, Bugge C. The epidemiology and societal costs of myasthenia gravis in Norway: A non-interventional study using national registry data. Eur J Neurol 2024; 31:e16233. [PMID: 38323756 DOI: 10.1111/ene.16233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/14/2023] [Accepted: 01/25/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND AND PURPOSE With the emergence of new treatment options for myasthenia gravis (MG), there is a need for information regarding epidemiology, healthcare utilization, and societal costs to support economic evaluation and identify eligible patients. We aimed to enhance the understanding of these factors using nationwide systematic registry data in Norway. METHODS We received comprehensive national registry data from five Norwegian health- and work-related registries. The annual incidence and prevalence were estimated for the period 2013-2021 using nationwide hospital and prescription data. The direct, indirect (productivity losses) and intangible costs (value of lost life-years [LLY] and health-related quality of life [HRQoL]) related to MG were estimated over a period of 1 year. RESULTS In 2021, the incidence of MG ranged from 15 to 16 cases per year per million population depending on the registry used, while the prevalence varied between 208.9 and 210.3 per million population. The total annual societal costs of MG amounted to EUR 24,743 per patient, of which EUR 3592 (14.5%) were direct costs, EUR 8666 (35.0%) were productivity loss, and EUR 12,485 (50.5%) were lost value from LLY and reduced HRQoL. CONCLUSION The incidence and prevalence of MG are higher than previously estimated, and the total societal costs of MG are substantial. Our findings demonstrate that productivity losses, and the value of LLY and HRQoL constitute a considerable proportion of the total societal costs.
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Affiliation(s)
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Ivar Sønbø Kristiansen
- Oslo Economics, Oslo, Norway
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Public Health, Research Unit for General Practice, University of Southern Denmark, Odense M, Denmark
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Heider D, Stetefeld H, Meisel A, Bösel J, Artho M, Linker R, Angstwurm K, Neumann B. POLAR: prediction of prolonged mechanical ventilation in patients with myasthenic crisis. J Neurol 2024; 271:2875-2879. [PMID: 38329540 DOI: 10.1007/s00415-024-12208-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 02/09/2024]
Affiliation(s)
- Dominik Heider
- Department of Machine Learning for Medical Data, Institute for Computer Science, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
- Department of Data Science in Biomedicine, Faculty of Mathematics and Computer Science, University of Marburg, Marburg, Germany
| | - Henning Stetefeld
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Andreas Meisel
- Department of Neurology With Experimental Neurology, Neuroscience Clinical Research Center, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Johns Hopkins University Hospital, Baltimore, MD, USA
| | - Marie Artho
- Department of Data Science in Biomedicine, Faculty of Mathematics and Computer Science, University of Marburg, Marburg, Germany
| | - Ralf Linker
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Bernhard Neumann
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany.
- Department of Neurology, Donau-Isar-Klinikum Deggendorf, Perlasberger Straße 41, 94469, Deggendorf, Germany.
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Kline M, Fuller K, Gray K. Myasthenia Gravis in Pregnancy and the Newborn. Neoreviews 2024; 25:e228-e231. [PMID: 38556492 DOI: 10.1542/neo.25-3-e228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Meagan Kline
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kisti Fuller
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kendra Gray
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
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Hoffmann S, Verlohren S, Herdick M. [Myasthenia gravis-Gender aspects and family planning]. Nervenarzt 2024; 95:316-328. [PMID: 38499774 DOI: 10.1007/s00115-024-01640-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND There is evidence that gender-specific differences can influence the diagnostics, treatment and long-term disease course of myasthenia gravis (MG). In women the diagnosis is often made during childbearing age. OBJECTIVE Gender-specific differences in MG and relevant aspects in routine clinical practice are presented. In addition, current studies on family planning, pregnancy and childbirth in MG are highlighted and treatment recommendations are derived. MATERIAL AND METHODS Narrative literature review. RESULTS In addition to sociodemographic data, gender-specific differences encompass clinical as well as paraclinical factors, such as disease severity and antibody status. With few exceptions pregnancy is possible with good maternal and neonatal outcome. During pregnancy and peripartum, children of MG patients should be closely monitored for early detection and treatment of potential syndromes caused by diaplacental transfer of maternal antibodies. CONCLUSION Gender-specific factors can influence the course of MG. Adequate medical counselling and multidisciplinary collaboration are essential for MG patients who wish to have children.
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Affiliation(s)
- Sarah Hoffmann
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Stefan Verlohren
- Department of Obstetrics, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Meret Herdick
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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Gutschmidt K, Schoser B. [Myasthenia Gravis - Update]. Fortschr Neurol Psychiatr 2024; 92:139-156. [PMID: 38636491 DOI: 10.1055/a-2238-7784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Myasthenia gravis - still a challenge for sufferers and doctors in 2023. But which therapy is best suited? Our clinically experienced experts have summarized the current guidelines for diagnosis and treatment in order to provide optimal support for those affected. Find out how you can carry out a quick and targeted diagnosis and which treatment options are available to alleviate the course of the disease.
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Kline M, Fuller K, Gray K. Myasthenia Gravis in Pregnancy and the Newborn. Neoreviews 2024; 25:e228-e231. [PMID: 38556501 DOI: 10.1542/neo.25-4-e228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Meagan Kline
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kisti Fuller
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
| | - Kendra Gray
- Department of Obstetrics and Gynecology, University of Arizona Phoenix College of Medicine, Banner University Medical Center, Phoenix, AZ
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Tian DS, Qin C, Dong MH, Heming M, Zhou LQ, Wang W, Cai SB, You YF, Shang K, Xiao J, Wang D, Li CR, Zhang M, Bu BT, Meyer Zu Hörste G, Wang W. B cell lineage reconstitution underlies CAR-T cell therapeutic efficacy in patients with refractory myasthenia gravis. EMBO Mol Med 2024; 16:966-987. [PMID: 38409527 PMCID: PMC11018773 DOI: 10.1038/s44321-024-00043-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 02/28/2024] Open
Abstract
B-cell maturation antigen (BCMA), expressed in plasmablasts and plasma cells, could serve as a promising therapeutic target for autoimmune diseases. We reported here chimeric antigen receptor (CAR) T cells targeting BCMA in two patients with highly relapsed and refractory myasthenia gravis (one with AChR-IgG, and one with MuSk-IgG). Both patients exhibited favorable safety profiles and persistent clinical improvements over 18 months. Reconstitution of B-cell lineages with sustained reduced pathogenic autoantibodies might underlie the therapeutic efficacy. To identify the possible mechanisms underlying the therapeutic efficacy of CAR-T cells in these patients, longitudinal single-cell RNA and TCR sequencing was conducted on serial blood samples post infusion as well as their matching infusion products. By tracking the temporal evolution of CAR-T phenotypes, we demonstrated that proliferating cytotoxic-like CD8 clones were the main effectors in autoimmunity, whereas compromised cytotoxic and proliferation signature and profound mitochondrial dysfunction in CD8+ Te cells before infusion and subsequently defect CAR-T cells after manufacture might explain their characteristics in these patients. Our findings may guide future studies to improve CAR T-cell immunotherapy in autoimmune diseases.
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Affiliation(s)
- Dai-Shi Tian
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Chuan Qin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Ming-Hao Dong
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Michael Heming
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Luo-Qi Zhou
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Wen Wang
- Nanjing IASO Biotechnology Co., Ltd, 210018, Nanjing, China
| | - Song-Bai Cai
- Nanjing IASO Biotechnology Co., Ltd, 210018, Nanjing, China
| | - Yun-Fan You
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Ke Shang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Jun Xiao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Di Wang
- Department of Hematology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Chun-Rui Li
- Department of Hematology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Min Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Bi-Tao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China
| | - Gerd Meyer Zu Hörste
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany.
| | - Wei Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030, Wuhan, China.
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction, Huazhong University of Science and Technology, 430030, Wuhan, China.
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Sivadasan A, Cortel-LeBlanc MA, Cortel-LeBlanc A, Katzberg H. Peripheral nervous system and neuromuscular disorders in the emergency department: A review. Acad Emerg Med 2024; 31:386-397. [PMID: 38419365 DOI: 10.1111/acem.14861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 11/30/2023] [Accepted: 12/21/2023] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Acute presentations and emergencies in neuromuscular disorders (NMDs) often challenge clinical acumen. The objective of this review is to refine the reader's approach to history taking, clinical localization and early diagnosis, as well as emergency management of neuromuscular emergencies. METHODS An extensive literature search was performed to identify relevant studies. We prioritized meta-analysis, systematic reviews, and position statements where possible to inform any recommendations. SUMMARY The spectrum of clinical presentations and etiologies ranges from neurotoxic envenomation or infection to autoimmune disease such as Guillain-Barré Syndrome (GBS) and myasthenia gravis (MG). Delayed diagnosis is not uncommon when presentations occur "de novo," respiratory failure is dominant or isolated, or in the case of atypical scenarios such as GBS variants, severe autonomic dysfunction, or rhabdomyolysis. Diseases of the central nervous system, systemic and musculoskeletal disorders can mimic presentations in neuromuscular disorders. CONCLUSIONS Fortunately, early diagnosis and management can improve prognosis. This article provides a comprehensive review of acute presentations in neuromuscular disorders relevant for the emergency physician.
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Affiliation(s)
- Ajith Sivadasan
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- 360 Concussion Care, Ottawa, Ontario, Canada
| | - Achelle Cortel-LeBlanc
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- 360 Concussion Care, Ottawa, Ontario, Canada
- Division of Neurology, Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Wang B, Zhu Y, Liu D, Hu C, Zhu R. The intricate dance of non-coding RNAs in myasthenia gravis pathogenesis and treatment. Front Immunol 2024; 15:1342213. [PMID: 38605954 PMCID: PMC11007667 DOI: 10.3389/fimmu.2024.1342213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/11/2024] [Indexed: 04/13/2024] Open
Abstract
Myasthenia gravis (MG) stands as a perplexing autoimmune disorder affecting the neuromuscular junction, driven by a multitude of antibodies targeting postsynaptic elements. However, the mystery of MG pathogenesis has yet to be completely uncovered, and its heterogeneity also challenges diagnosis and treatment. Growing evidence shows the differential expression of non-coding RNAs (ncRNAs) in MG has played an essential role in the development of MG in recent years. Remarkably, these aberrantly expressed ncRNAs exhibit distinct profiles within diverse clinical subgroups and among patients harboring various antibody types. Furthermore, they have been implicated in orchestrating the production of inflammatory cytokines, perturbing the equilibrium of T helper 1 cells (Th1), T helper 17 cells (Th17), and regulatory T cells (Tregs), and inciting B cells to generate antibodies. Studies have elucidated that certain ncRNAs mirror the clinical severity of MG, while others may hold therapeutic significance, showcasing a propensity to return to normal levels following appropriate treatments or potentially foretelling the responsiveness to immunosuppressive therapies. Notably, the intricate interplay among these ncRNAs does not follow a linear trajectory but rather assembles into a complex network, with competing endogenous RNA (ceRNA) emerging as a prominent hub in some cases. This comprehensive review consolidates the landscape of dysregulated ncRNAs in MG, briefly delineating their pivotal role in MG pathogenesis. Furthermore, it explores their promise as prospective biomarkers, aiding in the elucidation of disease subtypes, assessment of disease severity, monitoring therapeutic responses, and as novel therapeutic targets.
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Affiliation(s)
| | | | | | | | - Ruixia Zhu
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
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Salort-Campana E, Laforet P, de Pouvourville G, Crochard A, Chollet G, Nevoret C, Emery C, Bouée S, Tard C. Epidemiology of myasthenia gravis in France: A retrospective claims database study (STAMINA). Rev Neurol (Paris) 2024; 180:202-210. [PMID: 37945494 DOI: 10.1016/j.neurol.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/04/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The objectives of this observational study were to report the incidence and prevalence of myasthenia gravis (MG) in France, describe patients' characteristics and treatment patterns, and estimate mortality. METHODS A historical cohort analysis was performed using the French National Health Data System (SNDS) database between 2008 and 2020. Patients with MG were identified based on ICD-10 codes during hospitalization and/or long-term disease (ALD) status, which leads to a 100% reimbursement for healthcare expenses related to MG. The study population was matched to a control group based on age, sex and region of residence. RESULTS The overall incidence of MG was estimated at 2.5/100,000 in 2019 and the overall prevalence at 34.2/100,000. The mean age was 58.3 years for incident patients and 58.6 for prevalent patients. Among patients with MG, 57.1% were women. In the first year after identification of MG, acetylcholinesterase inhibitors were the most commonly used treatments (87.0%). Corticosteroids were delivered to 58.3% of patients, intravenous immunoglobulin to 34.4%, and azathioprine to 29.9%. Additionally, 8% of patients underwent thymectomy. The proportions of patients with exacerbations and crises were 59.7% and 13.5% respectively in the first year after MG identification. All-cause mortality was significantly higher in patients with MG compared to matched controls (HR=1.82 (95% CI [1.74;1.90], P<0.0001)). CONCLUSION In this study, the incidence and prevalence of MG estimated in France were found to be higher than previously reported. Most exacerbations and crises occurred within the first year after MG identification. MG was associated with increased mortality compared to a control population matched on age, gender, and geographical region.
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Affiliation(s)
- E Salort-Campana
- Service du Pr Attarian, Centre de référence des maladies neuromusculaires PACA Réunion Rhône Alpes, AP-HM, Marseille, France
| | - P Laforet
- Service de Neurologie, Hôpital Raymond Poincaré, Centre de référence des maladies neuromusculaires Nord-Est-Ile de France, FHU Phenix, Garches, France
| | | | | | | | | | - C Emery
- CEMKA, Bourg-La-Reine, France
| | - S Bouée
- CEMKA, Bourg-La-Reine, France
| | - C Tard
- Service de neurologie, U1172, Centre de référence des maladies neuromusculaires Nord/Est/Ile-de-France, CHU de Lille, Lille, France
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Sancho J, Ferrer S, Quezada A, Gimenez E, Signes-Costa J. Home Noninvasive Ventilation in Myasthenia Gravis. Respir Care 2024; 69:333-338. [PMID: 37935525 PMCID: PMC10984589 DOI: 10.4187/respcare.11308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Noninvasive ventilation (NIV) plays an important role in avoiding endotracheal intubation during myasthenic crisis, yet there are few published data concerning long-term home NIV in stable out-patients with myasthenia gravis (MG). The aim of this study was to describe the prevalence of NIV in a cohort of subjects with stable MG and to analyze contributing factors that could predict the need of NIV. METHODS We performed a cross-sectional study that included subjects diagnosed with MG managed in the respiratory care unit over the previous year. Subjects underwent clinical analysis including demographic, clinical, and functional respiratory data. RESULTS Of the 50 subjects included, 35 (70%) were positive for nicotinic acetylcholine receptor antibodies, and 68% had a diagnosis of generalized MG. Bulbar symptoms developed in 16 (32%), and 10 (20%) subjects needed long-term home NIV. The only variable predicting the need for long-term NIV was MG severity measured with Myasthenia Gravis Foundation of America (MGFA), mainly grades IIB (odds ratio 0.14 [95% CI 0.02-0.85], P = .03) and IIIB (odds ratio 0.02 [95% CI 0.01-0.34], P = .01). CONCLUSIONS Home NIV was needed in a substantial percentage of medically stable subjects with MG, mainly in those with generalized type and with oropharyngeal and/or respiratory muscle involvement (MGFA grades IIB and IIIB).
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Affiliation(s)
- Jesús Sancho
- Drs Sancho, Ferrer, Quezada, and Gimenez are affiliated with Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; and Institute of Health Research INCLIVA, Valencia, Spain. Dr signes-costa is affiliated with Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; Institute of Health Research INCLIVA, Valencia, Spain; and University of Valencia, Valencia, Spain.
| | - Santos Ferrer
- Drs Sancho, Ferrer, Quezada, and Gimenez are affiliated with Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; and Institute of Health Research INCLIVA, Valencia, Spain. Dr signes-costa is affiliated with Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; Institute of Health Research INCLIVA, Valencia, Spain; and University of Valencia, Valencia, Spain
| | - Antonio Quezada
- Drs Sancho, Ferrer, Quezada, and Gimenez are affiliated with Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; and Institute of Health Research INCLIVA, Valencia, Spain. Dr signes-costa is affiliated with Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; Institute of Health Research INCLIVA, Valencia, Spain; and University of Valencia, Valencia, Spain
| | - Elia Gimenez
- Drs Sancho, Ferrer, Quezada, and Gimenez are affiliated with Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; and Institute of Health Research INCLIVA, Valencia, Spain. Dr signes-costa is affiliated with Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; Institute of Health Research INCLIVA, Valencia, Spain; and University of Valencia, Valencia, Spain
| | - Jaime Signes-Costa
- Drs Sancho, Ferrer, Quezada, and Gimenez are affiliated with Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; and Institute of Health Research INCLIVA, Valencia, Spain. Dr signes-costa is affiliated with Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; Institute of Health Research INCLIVA, Valencia, Spain; and University of Valencia, Valencia, Spain
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McCallion J, Borsi A, Noel W, Lee J, Karmous W, Sattler S, Boggia GM, Hardy EJ, Mitchell CR, Mitchell SA, Gilhus NE. Systematic review of the patient burden of generalised myasthenia gravis in Europe, the Middle East, and Africa. BMC Neurol 2024; 24:61. [PMID: 38336636 PMCID: PMC10858594 DOI: 10.1186/s12883-024-03553-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is a rare autoimmune disease characterised by muscle weakness, and progression from ocular (oMG) to generalised (gMG) symptoms results in a substantial negative impact on quality of life (QoL). This systematic review aimed to provide an overview of the patient burden experienced by people living with gMG. METHODS Electronic database searches (conducted March 2022), supplemented by interrogation of grey literature, were conducted to identify studies reporting patient burden outcomes in patients with gMG in Europe, the Middle East and Africa. Results were synthesised narratively due to the heterogeneity across trials. RESULTS In total, 39 patient burden publications (representing 38 unique studies) were identified as relevant for inclusion in the systematic review, consisting of 37 publications reporting formal patient-reported outcome measures (PROMs), and two publications describing alternative qualitative assessments of patient experience. The studies included a variety of measures including generic and disease-specific PROMs, as well as symptom-specific PROMs focusing on key comorbidities including depression, anxiety, fatigue and sleep disturbance. The findings showed some variation across studies and PROMs; however, in general there was evidence for worse QoL in patients with gMG than in healthy controls or in patients with oMG, and a trend for worsening QoL with increasing MG severity. CONCLUSIONS This review highlights the importance of considering patient QoL when developing and assessing treatment and management plans for patients with gMG. However, the heterogeneity identified across studies illustrates the need for further representative and well-powered studies in large cohorts administering consistent, validated questionnaires. TRIAL REGISTRATION The protocol for this systematic review was registered in PROSPERO: CRD42022328444.
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Affiliation(s)
| | - A Borsi
- Janssen EMEA, Beerse, Belgium
| | - W Noel
- Janssen EMEA, Beerse, Belgium
| | - J Lee
- Janssen EMEA, Beerse, Belgium
| | | | | | | | - E J Hardy
- Mtech Access, Bicester, Oxfordshire, UK
| | | | | | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.
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14
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Golsorkhi M, Norouzi S, Abdipour A. An increase in fibrinogen levels despite plasma exchange in a myasthenia gravis patient; a case report. Ther Apher Dial 2024; 28:162-163. [PMID: 37503708 DOI: 10.1111/1744-9987.14041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 07/09/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Mohadese Golsorkhi
- Department of Medicine, Division of Nephrology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Sayna Norouzi
- Department of Medicine, Division of Nephrology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Amir Abdipour
- Department of Medicine, Division of Nephrology, Loma Linda University Medical Center, Loma Linda, California, USA
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15
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Su M, Luo Q, Wu Z, Feng H, Zhou H. Thymoma-associated autoimmune encephalitis with myasthenia gravis: Case series and literature review. CNS Neurosci Ther 2024; 30:e14568. [PMID: 38421083 PMCID: PMC10850820 DOI: 10.1111/cns.14568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 11/20/2023] [Accepted: 12/02/2023] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVES This comprehensive review aimed to compile cases of patients with thymoma diagnosed with both autoimmune encephalitis (AE) and myasthenia gravis (MG), and describe their clinical characteristics. METHODS Clinical records of 3 AE patients in the first affiliated hospital of Sun Yat-sen University were reviewed. All of them were diagnosed with AE between 1 November 2021 and 1 March 2022, and clinical evidence about thymoma and MG was found. All published case reports were searched for comprehensive literature from January 1990 to June 2022. RESULTS A total of 18 cases diagnosed with thymoma-associated autoimmune encephalitis (TAAE) and thymoma-associated myasthenia gravis (TAMG) were included in this complication, wherein 3 cases were in the first affiliated hospital of Sun Yat-sen University and the other 15 were published case reports. 5/18 patients had alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor antibody (AMPAR-Ab) in their serum and cerebrospinal fluid (CSF). All of them had positive anti-acetylcholine receptor antibody (AChR-Ab). And 12/18 patients showed a positive response to thymectomy and immunotherapy. Besides, thymoma recurrences were detected because of AE onset. And the shortest interval between operation and AE onset was 2 years in patients with thymoma recurrence. CONCLUSIONS There was no significant difference in the clinical manifestations between these patients and others with only TAMG or TAAE. TAAE was commonly associated with AMPAR2-Ab. Significantly, AE more commonly heralded thymoma recurrences than MG onset. And the intervals of thymectomy and MG or AE onset had different meanings for thymoma recurrence and prognoses of patients.
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Affiliation(s)
- Miao Su
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Qiuyan Luo
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
- Department of NeurologyGuangzhou Women and Children's Medical CenterGuangzhouChina
| | - Zichao Wu
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Huiyu Feng
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Hongyan Zhou
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
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16
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Habib AA, Sacks N, Cool C, Durgapal S, Dennen S, Everson K, Hughes T, Hernandez J, Phillips G. Hospitalizations and Mortality From Myasthenia Gravis: Trends From 2 US National Datasets. Neurology 2024; 102:e207863. [PMID: 38165317 DOI: 10.1212/wnl.0000000000207863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 10/03/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Myasthenia gravis (MG) is a rare neuromuscular disorder where IgG antibodies damage the communication between nerves and muscles, leading to muscle weakness that can be severe and have a significant impact on patients' lives. MG exacerbations include myasthenic crisis with respiratory failure, the most serious manifestation of MG. Recent studies have found MG prevalence increasing, especially in older patients. This study examined trends in hospital admissions and in-hospital mortality for adult patients with MG and readmissions and postdischarge mortality in older (65 years or older) adults with MG. METHODS Data from the Nationwide Inpatient Sample (NIS), an all-payer national database of hospital discharges, were used to characterize trends in hospitalizations and in-hospital mortality related to MG exacerbations and MG crisis among adult patients aged 18 years or older. The Medicare Limited Data Set, a deidentified, longitudinal research database with demographic, enrollment, and claims data was used to assess hospitalizations, length of stay (LOS), readmissions, and 30-day postdischarge mortality among fee-for-service Medicare beneficiaries aged 65 years or older. The study period was 2010-2019. Multinomial logit models and Poisson regression were used to test for significance of trends. RESULTS Hospitalization rates for 19,715 unique adult patients and 56,822 admissions increased from 2010 to 2019 at an average annualized rate of 4.9% (MG noncrisis: 4.4%; MG crisis: 6.8%; all p < 0.001). Readmission rates were approximately 20% in each study year for both crisis and noncrisis hospitalizations; the in-hospital mortality rate averaged 1.8%. Among patients aged 65 years or older, annualized increases in hospitalizations were estimated at 5.2%, 4.2%, and 7.7% for all, noncrisis, and crisis hospitalizations, respectively (all p < 0.001). The average LOS was stable over the study period, ranging from 11.3 to 13.1 days, but was consistently longer for MG crisis admissions. Mortality among patients aged 65 years or older was higher compared with that in all patients, averaging 5.0% across each of the study years. DISCUSSION Increasing hospitalization rates suggest a growing burden associated with MG, especially among older adults. While readmission and mortality rates have remained stable, the increasing hospitalization rates indicate that the raw numbers of readmissions-and deaths-are also increasing. Mortality rates are considerably higher in older patients hospitalized with MG.
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Affiliation(s)
- Ali A Habib
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Naomi Sacks
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Christina Cool
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Sneha Durgapal
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Syvart Dennen
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Katie Everson
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Tom Hughes
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Jennifer Hernandez
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Glenn Phillips
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
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Xue H, Zeng L, He H, Xu D, Ren K. Effects of acupuncture treatment for myasthenia gravis: A systematic review and meta-analysis. PLoS One 2024; 19:e0291685. [PMID: 38165870 PMCID: PMC10760751 DOI: 10.1371/journal.pone.0291685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/03/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) of acupuncture for myasthenia gravis (MG) were searched and the efficacy of acupuncture in the treatment of MG was evaluated by meta-analysis. METHODS We searched for RCTs in six main electronic databases, and collected RCTs of acupuncture treatment for MG from database creation to 28 February 2023. The main outcome was the effective rate and the secondary outcome was the Traditional Chinese Medicine (TCM) relative clinical score, absolute clinical score (ACS) of MG, Quantitive myasthenia gravis score (QMG), quality of life, and adverse events. Odds ratios (ORs) and weighted mean differences (WMD) and 95% confidence intervals (CI) were used to assess pooled effect estimates using Review Manager software. RESULTS A total of 14 RCTs were included. Meta-analysis showed that the effective rate in the acupuncture group was significantly improved compared with conventional Western medicine alone [OR = 4.28, 95% CI (2.95, 6, 22), P<0.005]. The pooled WMDs revealed that TCM relative clinical score [WMD = -2.22, 95% CI = (-2.53, -1.90), P<0.005], ACS of MG [WMD = -3.14, 95% CI = (-3.67, -2.62), P<0.005], and QMG [WMD = -0.88, 95% CI = (-1.46, -0.29), P<0.005] in the acupuncture group was lower than the control group. Adverse reactions related to acupuncture and quality of life were less mentioned among included RCTs. CONCLUSION This meta-analysis demonstrated that acupuncture as an auxiliary may play a positive role in treating MG. It can improve the effective rate of treatment, and reduce TCM relative clinical score, ACS of MG, and QMG. However, the quality of included studies was generally low and caution should be exercised when considering this treatment option. In the future, more rigorous study designs and high-quality RCTs are needed to verify the efficacy of acupuncture in the treatment of MG, because the results of high-quality RCTs are more reliable and accurate.
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Affiliation(s)
- Hua Xue
- Department of Neurology, Sichuan Taikang Hospital, Chengdu, Sichuan, China
| | - Li Zeng
- Department of Respiratory, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, Guangxi, China
| | - Hongxian He
- Department of Rehabilitation, Sichuan Taikang Hospital, Chengdu, Sichuan, China
| | - Dongxun Xu
- Department of Neurology, Sichuan Taikang Hospital, Chengdu, Sichuan, China
| | - Kaixin Ren
- Affiliated Hospital of Yunnan University, Kunming, Yunnan, China
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18
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Pisc J, Ting A, Skornicki M, Sinno O, Lee E. Healthcare resource utilization, costs and treatment associated with myasthenia gravis exacerbations among patients with myasthenia gravis in the USA: a retrospective analysis of claims data. J Comp Eff Res 2024; 13:e230108. [PMID: 38099519 PMCID: PMC10842297 DOI: 10.57264/cer-2023-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/27/2023] [Indexed: 01/06/2024] Open
Abstract
Aim: There are limited data on the clinical and economic burden of exacerbations in patients with myasthenia gravis (MG). We assessed patient clinical characteristics, treatments and healthcare resource utilization (HCRU) associated with MG exacerbation. Patients & methods: This was a retrospective analysis of adult patients with MG identified by commercial, Medicare or Medicaid insurance claims from the IBM® MarketScan® database. Eligible patients had two or more MG diagnosis codes, without evidence of exacerbation or crisis in the baseline period (12 months prior to index [first eligible MG diagnosis]). Clinical characteristics were evaluated at baseline and 12 weeks before each exacerbation. Number of exacerbations, MG treatments and HCRU costs associated with exacerbation were described during a 2-year follow-up period. Results: Among 9352 prevalent MG patients, 34.4% (n = 3218) experienced ≥1 exacerbation after index: commercial, 53.0% (n = 1706); Medicare, 39.4% (n = 1269); and Medicaid, 7.6% (n = 243). During follow-up, the mean (standard deviation) number of exacerbations per commercial and Medicare patient was 3.7 (7.0) and 2.7 (4.1), respectively. At least two exacerbations were experienced by approximately half of commercial and Medicare patients with ≥1 exacerbation. Mean total MG-related healthcare costs per exacerbation ranged from $26,078 to $51,120, and from $19,903 to $49,967 for commercial and Medicare patients, respectively. AChEI use decreased in patients with multiple exacerbations, while intravenous immunoglobulin use increased with multiple exacerbations. Conclusion: Despite utilization of current treatments for MG, MG exacerbations are associated with a high clinical and economic burden in both commercial and Medicare patients. Additional treatment options and improved disease management may help to reduce exacerbations and disease burden.
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19
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Suzuki S. [Clinical Features of Myasthenia Gravis as an Immune-related Adverse Event]. Brain Nerve 2024; 76:27-32. [PMID: 38191136 DOI: 10.11477/mf.1416202554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Neurological and muscular immune-related adverse events (irAEs) associated with cancer treatment using immune checkpoint inhibitors (ICIs) may show a diverse clinical presentation. Myasthenia gravis (MG) represents a serious irAE associated with the aforementioned therapy. Recent studies have discussed the clinical features of MG that occurs as an irAE (irAE-MG). The incidence of irAE-MG is estimated to be 1%. This complication occurs during the early phase of ICI treatment and rapidly worsens, resulting in severe bulbar muscle involvement and myasthenic crisis and significantly elevated serum creatine kinase levels. MG and myositis, which may occur concomitantly as irAEs are often indistinguishable. Myocarditis is occasionally observed in patients with irAE-MG and can cause severe heart failure and lethal arrhythmias, with a fatal outcome. Kv1.4 antibodies serve as biomarkers of severe irAE-MG and myocarditis. Immunotherapy with corticosteroids is effective for management of irAE-MG and should be initiated promptly. Collaboration between consulting neurologists is necessary for safe management of cancer immunotherapy.
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20
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Tannemaat MR, Huijbers MG, Verschuuren JJGM. Myasthenia gravis-Pathophysiology, diagnosis, and treatment. Handb Clin Neurol 2024; 200:283-305. [PMID: 38494283 DOI: 10.1016/b978-0-12-823912-4.00026-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by dysfunction of the neuromuscular junction resulting in skeletal muscle weakness. It is equally prevalent in males and females, but debuts at a younger age in females and at an older age in males. Ptosis, diplopia, facial bulbar weakness, and limb weakness are the most common symptoms. MG can be classified based on the presence of serum autoantibodies. Acetylcholine receptor (AChR) antibodies are found in 80%-85% of patients, muscle-specific kinase (MuSK) antibodies in 5%-8%, and <1% may have low-density lipoprotein receptor-related protein 4 (Lrp4) antibodies. Approximately 10% of patients are seronegative for antibodies binding the known disease-related antigens. In patients with AChR MG, 10%-20% have a thymoma, which is usually detected at the onset of the disease. Important differences between clinical presentation, treatment responsiveness, and disease mechanisms have been observed between these different serologic MG classes. Besides the typical clinical features and serologic testing, the diagnosis can be established with additional tests, including repetitive nerve stimulation, single fiber EMG, and the ice pack test. Treatment options for MG consist of symptomatic treatment (such as pyridostigmine), immunosuppressive treatment, or thymectomy. Despite the treatment with symptomatic drugs, steroid-sparing immunosuppressants, intravenous immunoglobulins, plasmapheresis, and thymectomy, a large proportion of patients remain chronically dependent on corticosteroids (CS). In the past decade, the number of treatment options for MG has considerably increased. Advances in the understanding of the pathophysiology have led to new treatment options targeting B or T cells, the complement cascade, the neonatal Fc receptor or cytokines. In the future, these new treatments are likely to reduce the chronic use of CS, diminish side effects, and decrease the number of patients with refractory disease.
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Affiliation(s)
- Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje G Huijbers
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
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21
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Uzawa A, Yamashita J, Kuwabara S. [Acetylcholine Receptor Antibody Neutralization and Selective B-Cell Suppression Using Fc Fusion Protein]. Brain Nerve 2024; 76:69-72. [PMID: 38191142 DOI: 10.11477/mf.1416202560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by formation of autoantibodies against the nicotinic acetylcholine receptor (AChR). Some patients do not show sufficient improvement and develop adverse effects following administration of conventional immune therapy; therefore, the development of new treatments is important. Based on the concept of "selective removal of pathogenic antibodies and cells without suppression of normal immunity," we are developing a fusion protein referred to as AChR-Fc (composed of the AChR alpha subunit and Fc region of human immunoglobulin G1), which shows the following mechanisms of action: selective neutralization of AChR antibodies and cytotoxic activity against AChR antibody-producing pathogenic B cells. Treatment with AChR-Fc is a novel therapeutic approach that may be useful in the management of MG.
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Affiliation(s)
- Akiyuki Uzawa
- Department of Neurology, Graduate School of Medicine, Chiba University
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22
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Neumann B, Angstwurm K, Dohmen C, Mergenthaler P, Kohler S, Schönenberger S, Lee DH, Gerner ST, Huttner HB, Thieme A, Steinbrecher A, Dunkel J, Roth C, Schneider H, Reichmann H, Fuhrer H, Kleiter I, Schneider-Gold C, Alberty A, Zinke J, Schroeter M, Linker R, Meisel A, Bösel J, Stetefeld HR. Weaning and extubation failure in myasthenic crisis: a multicenter analysis. J Neurol 2024; 271:564-574. [PMID: 37923937 DOI: 10.1007/s00415-023-12016-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/06/2023]
Abstract
Myasthenic crisis (MC) requiring mechanical ventilation is a serious complication of myasthenia gravis (MG). Here we analyze the frequency and risk factors of weaning- and extubation failure as well as its impact on the clinical course in a large cohort. We performed a retrospective chart review on patients treated for MC in 12 German neurological departments between 2006 and 2015. Weaning failure (WF) was defined as negative spontaneous breathing trial, primary tracheostomy, or extubation failure (EF) (reintubation or death). WF occurred in 138 episodes (64.2%). Older Age (p = 0.039), multiple comorbidities (≥ 3) (p = 0.007, OR = 4.04), late-onset MG (p = 0.004, OR = 2.84), complications like atelectasis (p = 0.008, OR = 3.40), pneumonia (p < 0.0001, OR = 3.45), cardio-pulmonary resuscitation (p = 0.005, OR = 5.00) and sepsis (p = 0.02, OR = 2.57) were associated with WF. WF occurred often in patients treated with intravenous immungloblins (IVIG) (p = 0.002, OR = 2.53), whereas WF was less often under first-line therapy with plasma exchange or immunoadsorption (p = 0.07, OR = 0.57). EF was observed in 58 of 135 episodes (43.0%) after first extubation attempt and was related with prolonged mechanical ventilation, intensive care unit stay and hospital stay (p ≤ 0.0001 for all). Extubation success was most likely in a time window for extubation between day 7 and 12 after intubation (p = 0.06, OR = 2.12). We conclude that WF and EF occur very often in MC and are associated with poor outcome. Older age, multiple comorbidities and development of cardiac and pulmonary complications are associated with a higher risk of WF and EF. Our data suggest that WF occurs less frequently under first-line plasma exchange/immunoadsorption compared with first-line use of IVIG.
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Affiliation(s)
- Bernhard Neumann
- Department of Neurology, Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Dohmen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Department for Neurology and Neurological Intensive Care Medicine, LVR-Klinik Bonn, Bonn, Germany
| | - Philipp Mergenthaler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Siegfried Kohler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Department of Neurology, Sana Klinikum Landkreis Biberach, Biberach, Germany
| | | | - De-Hyung Lee
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Andrea Thieme
- Department of Neurology, HELIOS Klinikum Erfurt, Erfurt, Germany
| | | | - Juliane Dunkel
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hannah Fuhrer
- Department of Neurology, Medical Center-University of Freiburg, Freiburg, Germany
- Department of Neurology, HELIOS Klinik Mühlheim, Mühlheim, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Anke Alberty
- Department of Neurology, Kliniken Maria Hilf GmbH Moenchengladbach, Moenchengladbach, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Michael Schroeter
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Ralf Linker
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Henning R Stetefeld
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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23
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Giudicissi A, Vetrano D, Morresi S, Bruno PF, Neri L, Signorotti S, Sgarlato V, Ruggeri M, Zanchelli F, Longoni M, Buscaroli A. [Therapeutic Plasma Exchange in a Patient with Chronic Hemodialysis and a New Diagnosis of Myasthenia Gravis]. G Ital Nefrol 2023; 40:2023-vol6. [PMID: 38156541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Case ReportC.S.T. (♂, 71 years old) is a patient with multiple and severe comorbidities, undergoing thrice-weekly chronic hemodialysis since 2008 due to the progression of post-lithiasic uropathy. Over the past 2 months, the patient had been experiencing progressive ptosis of the eyelids, muscle weakness, and ultimately dysphagia and dysarthria that emerged in the last few days. Urgently admitted to the Neurology department, electromyography (EMG) was performed, leading to a diagnosis of predominant cranial myasthenia gravis (with borderline anti-acetylcholine receptor antibody serology). Prompt treatment with pyridostigmine and steroids was initiated. Considering the high risk of acute myasthenic decompensation, therapeutic plasma exchange (TPE) with centrifugation technique was promptly undertaken after femoral CVC placement. TPE sessions were alternated with hemodialysis. The patient's condition complicated after the third TPE session, with septic shock caused by Methicillin-Sensitive Staphylococcus Aureus (MSSA). The patient was transferred to the Intensive Care Unit (ICU). Due to hemodynamic instability, continuous veno-venous hemodiafiltration (CVVHDF) with citrate anticoagulation was administered for 72 hours. After resolving the septic condition, intermittent treatment with Acetate-Free Biofiltration (AFB) technique was resumed. The patient completed the remaining three TPE sessions and, once the acute condition was resolved, was transferred back to Neurology. Here, the patient continued the treatment and underwent a rehabilitation program, showing significant motor and functional recovery until discharge. Conclusions. The multidisciplinary interaction among Nephrologists, Neurologists, Anesthesiologists, and experts from the Immunohematology and Transfusion Medicine Service enabled the management and treatment of a rare condition (MG) in a high-risk chronic hemodialysis patient.
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Affiliation(s)
- A Giudicissi
- Unità Operativa di Nefrologia e Dialisi, Ospedale "M. Bufalini", Cesena, Italia
| | - D Vetrano
- Unità Operativa di Nefrologia, Dialisi e Trapianto, IRCCS Azienda Ospedialiero Universitaria di Bologna, 40138, Bologna, Italia
| | - S Morresi
- Unità Operativa di Neurologia e Stroke Unit, Ospedale "M. Bufalini", Cesena, Italia
| | - P F Bruno
- Unità Operativa di Nefrologia e Dialisi, Ospedale "M. Bufalini", Cesena, Italia
| | - L Neri
- Unità Operativa di Nefrologia e Dialisi, Ospedale "M. Bufalini", Cesena, Italia
| | - S Signorotti
- Unità Operativa di Nefrologia e Dialisi, Ospedale "M. Bufalini", Cesena, Italia
| | - V Sgarlato
- Unità Operativa di Nefrologia e Dialisi, Ospedale "M. Bufalini", Cesena, Italia
| | - M Ruggeri
- Unità Operativa di Nefrologia e Dialisi, Ospedale "M. Bufalini", Cesena, Italia
| | - F Zanchelli
- Unità Operativa di Nefrologia e Dialisi, Ospedale "M. Bufalini", Cesena, Italia
| | - M Longoni
- Unità Operativa di Neurologia e Stroke Unit, Ospedale "M. Bufalini", Cesena, Italia
| | - A Buscaroli
- Unità Operativa di Nefrologia e Dialisi, Ospedale "M. Bufalini", Cesena, Italia
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24
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Katyal N, Katsumoto TR, Ramachandran KJ, Yunce M, Muppidi S. Plasma Exchange in Patients With Myositis due to Immune Checkpoint Inhibitor Therapy. J Clin Neuromuscul Dis 2023; 25:89-93. [PMID: 37962196 PMCID: PMC10645099 DOI: 10.1097/cnd.0000000000000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
ABSTRACT Immune checkpoint inhibitors used to treat malignancies may lead to various immune-related adverse events (irAEs) including conditions such as myositis and myasthenia gravis (MG). Here, we describe 2 cases of myositis treated effectively with therapeutic plasma exchange (PLEX). A 64-year-old man with thymic cancer developed leg weakness and dyspnea 1 month after the second dose of nivolumab with moderate weakness in proximal and distal muscles, with elevated creatine kinase levels. Another 77-year-old man with Stage IIIB squamous cell carcinoma of the lung developed progressive proximal muscle weakness and became nonambulatory after cycle 2 of durvalumab with persistently high creatine kinase levels despite prednisone treatment. Electrophysiology revealed irritative myopathy without evidence of neuromuscular junction dysfunction and MG antibody testing was nonrevealing. With PLEX, both patients noticed rapid improvement in strength. PLEX in conjunction with other immunosuppressive agents can result in rapid improvement in irAE-myositis even in patients without associated MG.
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Affiliation(s)
- Nakul Katyal
- Department of Neurology, Stanford University School of Medicine, Stanford, CA
| | - Tamiko R. Katsumoto
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Kavitha J. Ramachandran
- Division of Oncology, Department of Medicine, Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA; and
| | - Muharrem Yunce
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Srikanth Muppidi
- Department of Neurology, Stanford University School of Medicine, Stanford, CA
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25
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Haghikia A, Hegelmaier T, Wolleschak D, Böttcher M, Desel C, Borie D, Motte J, Schett G, Schroers R, Gold R, Mougiakakos D. Anti-CD19 CAR T cells for refractory myasthenia gravis. Lancet Neurol 2023; 22:1104-1105. [PMID: 37977704 DOI: 10.1016/s1474-4422(23)00375-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/20/2023] [Accepted: 09/22/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Aiden Haghikia
- Department of Neurology, Medical Faculty, Otto-von-Guericke University, Magdeburg 39120, Germany.
| | - Tobias Hegelmaier
- Department of Neurology, Medical Faculty, Otto-von-Guericke University, Magdeburg 39120, Germany
| | - Denise Wolleschak
- Department of Haematology and Oncology, Otto-von-Guericke University, Magdeburg 39120, Germany
| | - Martin Böttcher
- Department of Haematology and Oncology, Otto-von-Guericke University, Magdeburg 39120, Germany
| | - Christiane Desel
- Department of Neurology, Medical Faculty, Otto-von-Guericke University, Magdeburg 39120, Germany
| | | | - Jeremias Motte
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | - Georg Schett
- Department of Rheumatology, Friedrich-Alexander-University, Erlangen, Germany
| | - Roland Schroers
- Department of Haematology and Oncology, Ruhr University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology, Ruhr University Bochum, Bochum, Germany
| | - Dimitrios Mougiakakos
- Department of Haematology and Oncology, Otto-von-Guericke University, Magdeburg 39120, Germany
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26
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Adamu M, Saka F. Atypical Myasthenia gravis in an older person resulting in delayed diagnosis: a case report. Age Ageing 2023; 52:afad230. [PMID: 38156973 DOI: 10.1093/ageing/afad230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/11/2023] [Indexed: 01/03/2024] Open
Abstract
Myasthenia gravis (MG) is a rare autoimmune neuromuscular disorder characterised by varying degrees of skeletal muscle weakness. Diagnosing MG represents a challenge for clinicians due to the diversity of disease manifestations. We present an unusual case of this disease in an older gentleman in which the patient reported swollen tongue and lips which was incorrectly diagnosed and treated as angioedema. Months later, he developed progressive dysphagia, dysarthria and weight loss. The diagnosis was further delayed by the identification of a hiatal hernia and Zenker's diverticulum after extensive investigation for dysphagia. A total of 15 months on prompted by persistent symptoms, the patient was found to have MG by positive antibody test and Electromyogram. Treatment was initiated which led to a rapid and significant relief of his symptoms.
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Affiliation(s)
- Maimuna Adamu
- Department of Medicine, Peterborough City Hospital, Northwest Anglia NHS Foundation Trust, Peterborough, Cambridgeshire, UK
| | - Felix Saka
- Medicine for Older People, Peterborough City Hospital, Northwest Anglia NHS Foundation Trust, Peterborough, Cambridgeshire, UK
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27
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De Lott LB, Ehrlich JR. Patient-Reported Outcomes for Ocular Myasthenia Gravis: Response. J Neuroophthalmol 2023; 43:e357. [PMID: 35421027 PMCID: PMC9500114 DOI: 10.1097/wno.0000000000001512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Lindsey B. De Lott
- Department of Ophthalmology and Visual Sciences, Michigan
Medicine, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, Michigan
Medicine, Ann Arbor, Michigan, USA
| | - Joshua R. Ehrlich
- Department of Ophthalmology and Visual Sciences, Michigan
Medicine, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, Michigan
Medicine, Ann Arbor, Michigan, USA
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28
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Wong SH, Eggenberger ER, Cornblath WT. Patient-Reported Outcomes for Ocular Myasthenia Gravis. J Neuroophthalmol 2023; 43:356. [PMID: 35051983 DOI: 10.1097/wno.0000000000001511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Sui Hsien Wong
- Department of Neuro-ophthalmology, Moorfields Eye Hospital, London, United Kingdom , Department of Neuro-ophthalmology, Mayo Clinic Jacksonville, Jacksonville, Florida; and Department of Neuro-ophthalmology, University of Michigan, Ann Arbor, Michigan
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29
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Allen NM, O’Rahelly M, Eymard B, Chouchane M, Hahn A, Kearns G, Kim DS, Byun SY, Nguyen CTE, Schara-Schmidt U, Kölbel H, Marina AD, Schneider-Gold C, Roefke K, Thieme A, Van den Bergh P, Avalos G, Álvarez-Velasco R, Natera-de Benito D, Cheng MHM, Chan WK, Wan HS, Thomas MA, Borch L, Lauzon J, Kornblum C, Reimann J, Mueller A, Kuntzer T, Norwood F, Ramdas S, Jacobson LW, Jie X, Fernandez-Garcia MA, Wraige E, Lim M, Lin JP, Claeys KG, Aktas S, Oskoui M, Hacohen Y, Masud A, Leite MI, Palace J, De Vivo D, Vincent A, Jungbluth H. The emerging spectrum of fetal acetylcholine receptor antibody-related disorders (FARAD). Brain 2023; 146:4233-4246. [PMID: 37186601 PMCID: PMC10545502 DOI: 10.1093/brain/awad153] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023] Open
Abstract
In utero exposure to maternal antibodies targeting the fetal acetylcholine receptor isoform (fAChR) can impair fetal movement, leading to arthrogryposis multiplex congenita (AMC). Fetal AChR antibodies have also been implicated in apparently rare, milder myopathic presentations termed fetal acetylcholine receptor inactivation syndrome (FARIS). The full spectrum associated with fAChR antibodies is still poorly understood. Moreover, since some mothers have no myasthenic symptoms, the condition is likely underreported, resulting in failure to implement effective preventive strategies. Here we report clinical and immunological data from a multicentre cohort (n = 46 cases) associated with maternal fAChR antibodies, including 29 novel and 17 previously reported with novel follow-up data. Remarkably, in 50% of mothers there was no previously established myasthenia gravis (MG) diagnosis. All mothers (n = 30) had AChR antibodies and, when tested, binding to fAChR was often much greater than that to the adult AChR isoform. Offspring death occurred in 11/46 (23.9%) cases, mainly antenatally due to termination of pregnancy prompted by severe AMC (7/46, 15.2%), or during early infancy, mainly from respiratory failure (4/46, 8.7%). Weakness, contractures, bulbar and respiratory involvement were prominent early in life, but improved gradually over time. Facial (25/34; 73.5%) and variable peripheral weakness (14/32; 43.8%), velopharyngeal insufficiency (18/24; 75%) and feeding difficulties (16/36; 44.4%) were the most common sequelae in long-term survivors. Other unexpected features included hearing loss (12/32; 37.5%), diaphragmatic paresis (5/35; 14.3%), CNS involvement (7/40; 17.5%) and pyloric stenosis (3/37; 8.1%). Oral salbutamol used empirically in 16/37 (43.2%) offspring resulted in symptom improvement in 13/16 (81.3%). Combining our series with all previously published cases, we identified 21/85 mothers treated with variable combinations of immunotherapies (corticosteroids/intravenous immunoglobulin/plasmapheresis) during pregnancy either for maternal MG symptom control (12/21 cases) or for fetal protection (9/21 cases). Compared to untreated pregnancies (64/85), maternal treatment resulted in a significant reduction in offspring deaths (P < 0.05) and other complications, with treatment approaches involving intravenous immunoglobulin/ plasmapheresis administered early in pregnancy most effective. We conclude that presentations due to in utero exposure to maternal (fetal) AChR antibodies are more common than currently recognized and may mimic a wide range of neuromuscular disorders. Considering the wide clinical spectrum and likely diversity of underlying mechanisms, we propose 'fetal acetylcholine receptor antibody-related disorders' (FARAD) as the most accurate term for these presentations. FARAD is vitally important to recognize, to institute appropriate management strategies for affected offspring and to improve outcomes in future pregnancies. Oral salbutamol is a symptomatic treatment option in survivors.
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Affiliation(s)
- Nicholas M Allen
- Department of Paediatrics, School of Medicine, University of Galway, Galway H91 V4AY, Ireland
| | - Mark O’Rahelly
- Department of Paediatrics, School of Medicine, University of Galway, Galway H91 V4AY, Ireland
| | - Bruno Eymard
- Centre de référence des maladies neuromusculaires Nord/Est/Ile-de-France, Unité Pathologie Neuromusculaire, Bâtiment Babinski, G.H. Pitie-Salpetriere, 75013 Paris, France
| | - Mondher Chouchane
- Department of Pediatrics, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Andreas Hahn
- Department of Child Neurology, University Hospital Giessen, 35392 Giessen, Germany
| | - Gerry Kearns
- Department of Maxillofacial Surgery, St. James Hospital, Dublin D08 NHY1, Ireland
| | - Dae-Seong Kim
- Department of Neurology, Pusan National University, School of Medicine, Pusan 50612, South Korea
| | - Shin Yun Byun
- Department of Pediatrics, Pusan National University, School of Medicine, Pusan 50612, South Korea
| | - Cam-Tu Emilie Nguyen
- Pediatric Neurology, CHU Sainte-Justine and Département de neurosciences, Université de Montréal, QC, H3T 1C5, Canada
| | - Ulrike Schara-Schmidt
- Department of Pediatric Neurology, Centre for Translational Neuro- and Behavioral Sciences, University Duisburg, Essen, DE-45147 Essen, Germany
| | - Heike Kölbel
- Department of Pediatric Neurology, Centre for Translational Neuro- and Behavioral Sciences, University Duisburg, Essen, DE-45147 Essen, Germany
| | - Adela Della Marina
- Department of Pediatric Neurology, Centre for Translational Neuro- and Behavioral Sciences, University Duisburg, Essen, DE-45147 Essen, Germany
| | | | - Kathryn Roefke
- Klinik für Kinder- und Jugendmedizin, 99089 Erfurt, Germany
| | - Andrea Thieme
- Department of Neurology, Clinical Neurophysiology and Neurorehabilitation, St. Georg Klinikum, 99817 Eisenach, Germany
| | - Peter Van den Bergh
- Neuromuscular Reference Centre UCL St-Luc, University Hospital Saint-Luc, 1200 Brussels, Belgium
| | - Gloria Avalos
- Department of Medicine, University of Galway, Galway H91 V4AY, Ireland
| | - Rodrigo Álvarez-Velasco
- Unitat Patologia Neuromuscular, Servei Neurologia Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | | | - Man Hin Mark Cheng
- Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong
| | - Wing Ki Chan
- Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong
| | - Hoi Shan Wan
- Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong
| | - Mary Ann Thomas
- Department of Medical Genetics and Pediatrics, Cumming School of Medicine, University of Calgary, Alberta Children’s Hospital, Calgary, AB T3B 6A8, Canada
| | - Lauren Borch
- Department of Medical Genetics and Pediatrics, Cumming School of Medicine, University of Calgary, Alberta Children’s Hospital, Calgary, AB T3B 6A8, Canada
| | - Julie Lauzon
- Department of Medical Genetics and Pediatrics, Cumming School of Medicine, University of Calgary, Alberta Children’s Hospital, Calgary, AB T3B 6A8, Canada
| | - Cornelia Kornblum
- Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
- Center for Rare Diseases, University Hospital Bonn, 53127 Bonn, Germany
| | - Jens Reimann
- Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Andreas Mueller
- Department of Neonatology and Pediatric Intensive Care, University Hospital Bonn, 53127, Bonn, Germany
| | - Thierry Kuntzer
- Nerve-Muscle Unit, Department of Clinical Neurosciences, CHUV, University of Lausanne, 1011 Lausanne, Switzerland
| | - Fiona Norwood
- Department of Neurology, King’s College Hospital, London SE5 9RS, UK
| | - Sithara Ramdas
- MDUK Neuromuscular Centre, Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Leslie W Jacobson
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford OX3 9DU, UK
| | - Xiaobo Jie
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford OX3 9DU, UK
| | - Miguel A Fernandez-Garcia
- Department of Children’s Neurosciences, Evelina London Children's Hospital, Guy’s & St. Thomas’ Hospital NHS Foundation Trust, London SE1 7EH, UK
| | - Elizabeth Wraige
- Department of Children’s Neurosciences, Evelina London Children's Hospital, Guy’s & St. Thomas’ Hospital NHS Foundation Trust, London SE1 7EH, UK
| | - Ming Lim
- Department of Children’s Neurosciences, Evelina London Children's Hospital, Guy’s & St. Thomas’ Hospital NHS Foundation Trust, London SE1 7EH, UK
- Department of Women and Children’s Health, School of Life Course Sciences (SoLCS), King’s College London, London SE1 9NH, UK
| | - Jean Pierre Lin
- Department of Children’s Neurosciences, Evelina London Children's Hospital, Guy’s & St. Thomas’ Hospital NHS Foundation Trust, London SE1 7EH, UK
| | - Kristl G Claeys
- Department of Neurology, University Hospitals Leuven, 3000 Leuven, Belgium
- Laboratory for Muscle Diseases and Neuropathies, Department of Neurosciences, KU Leuven, and Leuven Brain Institute (LBI), 3000 Leuven, Belgium
| | - Selma Aktas
- Faculty of Medicine, Department of Pediatrics, Division of Neonatology, Acıbadem University, 34752 Istanbul, Turkey
| | - Maryam Oskoui
- Department of Pediatrics, McGill University, Montreal, QC H4A 3J1, Canada
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC H4A 3J1, Canada
- Centre for Outcomes Research and Evaluation, Research Institute McGill University Health Centre, Montreal, QC H3H 2R9, Canada
| | - Yael Hacohen
- Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London WC1N 3BG, UK
- Department of Neurology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | - Ameneh Masud
- Department of Neurology, Columbia University Irving Medical Center, New York, NY 10032-3791, USA
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032-3791, USA
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford OX3 9DU, UK
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford OX3 9DU, UK
| | - Darryl De Vivo
- Department of Neurology, Columbia University Irving Medical Center, New York, NY 10032-3791, USA
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032-3791, USA
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford OX3 9DU, UK
| | - Heinz Jungbluth
- Department of Children’s Neurosciences, Evelina London Children's Hospital, Guy’s & St. Thomas’ Hospital NHS Foundation Trust, London SE1 7EH, UK
- Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and Medicine (FoLSM), King’s College London, London SE1 1YR, UK
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30
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Çelebisoy N, Orujov A, Balayeva F, Özdemir HN, Ak AK, Gökçay F. Prognostic predictors of remission in ocular myasthenia gravis. Acta Neurol Belg 2023; 123:1927-1932. [PMID: 36474006 DOI: 10.1007/s13760-022-02151-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ocular myasthenia gravis (OMG) constitutes 15% of all myasthenia gravis patients. METHODS One hundred eight patients with OMG followed-up for over 36 months were retrospectively evaluated regarding factors associated with remission. Demographic features, neuro-ophthalmologic findings at onset, acetylcholine receptor (AChR Ab) and muscle-specifc tyrosine kinase antibodies (MuSK Ab), thymic status, single fiber electromyography (SFEMG) results were the variables considered. RESULTS Median age of disease onset was 57 years (range 18-82 years). Clinical features at onset was isolated ptosis in 55 (50.9%) and isolated diplopia in 33 (30.6%) patients. Combined ptosis and diplopia were present in 20 (18.5%) patients. Among 75 patients with ptosis, it was unilateral in 65 (86.7%) and bilateral in 10 (13.3%). AChR Abs were found in 66 (61.1%) and MuSK Abs in 2 (1.9%) patients. SFEMG abnormality was detected in 74 (68.5%) patients. Thymoma was present in 16 (14.8%) and thymic hyperplasia in 6 (5.6%) patients. Forty-one patients (37.9%) had been treated with pyridostigmine alone. Sixty-seven (62%) patients were given immunosupressive drugs. In 53 (49.1%) prednisone was used and in 14 (12.9%) patients it was combined with azathioprine. Thymectomy was performed in all 16 patients with thymoma. Complete stable remission (CSR) was achieved in 49 (45.4%) patients. Fifty-nine (54.6%) patients had reached minimal manifestation (MM) status; 32 (29.6%) having a status of MM-1 and 27 (25%) a status of MM-3. CONCLUSIONS The presence of AchR Abs (p = 0.034) and an abnormal SFEMG (p = 0.006) at onset as increased risk factors for the presence of ongoing signs necessitating medical treatment.
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Affiliation(s)
- Neşe Çelebisoy
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
| | - Asim Orujov
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
| | - Fidan Balayeva
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
| | | | - Ayşın Kısabay Ak
- Department of Neurology, Celal Bayar University Medical School, 45000, Manisa, Turkey.
| | - Figen Gökçay
- Department of Neurology, Ege University Medical School, 35100, Izmir, Turkey
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31
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Dewilde S, Phillips G, Paci S, De Ruyck F, Tollenaar NH, Janssen MF. People Diagnosed with Myasthenia Gravis have Lower health-related quality of life and Need More Medical and Caregiver Help in Comparison to the General Population: Analysis of Two Observational Studies. Adv Ther 2023; 40:4377-4394. [PMID: 37490259 PMCID: PMC10499690 DOI: 10.1007/s12325-023-02604-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/28/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Myasthenia gravis (MG) is a neuromuscular disease causing extreme muscular fatigue, triggering problems with vision, swallowing, speech, mobility, dexterity, and breathing. This analysis intended to estimate the health-related quality-of-life impact, the medical burden, and the need for caregiver help of people diagnosed with MG. METHODS MyRealWorld-MG (MRW) is an observational study among adults diagnosed with MG in 9 countries. The General Population Norms (POPUP) observational study enrolled representative members of the general population in 8 countries. In both digital studies, respondents entered personal characteristics and provided data on medical conditions, EQ-5D-5L, HUI3, MG-Activities of Daily Living (MG-ADL), sick leave, caregiver help, and medical care utilization. RESULTS In MRW (n = 1859), 58.4% of respondents had moderate-to-severe MG. Average utility values were lower in MRW versus POPUP (0.739 vs. 0.843 for EQ-5D-5L; 0.493 vs. 0.746 for HUI3), and declined with more severe disease (0.872, 0.707, 0.511 EQ-5D-5L utilities and 0.695, 0.443, 0.168 HUI3 utilities for mild, moderate, and severe MG, respectively). Taking sick leave in the past month was 2.6 times more frequent among people diagnosed with MG compared to the general population (34.4% vs. 13.2%) and four times more people diagnosed with MG reported needing help from a caregiver (34.8% vs. 8.3%). Use of medical care was twice as likely in MRW in comparison with POPUP (51.9% vs. 24.6%). CONCLUSION This direct comparison of people diagnosed with MG and the general population using two large international studies revealed significant negative impact of MG. Results were consistent across all outcomes, in all countries.
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Affiliation(s)
- S Dewilde
- Services in Health Economics (SHE), Rue JG Eggerickx 36, 1150, Brussels, Belgium.
| | | | - S Paci
- Argenx BV, Ghent, Belgium
| | | | - N H Tollenaar
- Services in Health Economics (SHE), Rue JG Eggerickx 36, 1150, Brussels, Belgium
| | - M F Janssen
- Section Medical Psychology and Psychotherapy, Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands
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Almodovar JL, Mehrabyan A. Disease-Based Prognostication: Myasthenia Gravis. Semin Neurol 2023; 43:799-806. [PMID: 37751854 DOI: 10.1055/s-0043-1775791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
Myasthenia gravis (MG) is an acquired autoimmune neuromuscular junction transmission disorder that clinically presents as fluctuating or persistent weakness in various skeletal muscle groups. Neuroprognostication in MG begins with some basic observations on the natural history of the disease and known treatment outcomes. Our objective is to provide a framework that can assist a clinician who encounters the MG patient for the first time and attempts to prognosticate probable outcomes in individual patients. In this review article, we explore clinical type, age of onset, antibody status, severity of disease, thymus pathology, autoimmune, and other comorbidities as prognostic factors in MG.
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Affiliation(s)
- Jorge L Almodovar
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anahit Mehrabyan
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Vinciguerra C, Bevilacqua L, Toriello A, Iovino A, Piscosquito G, Calicchio G, Barone P. Starting eculizumab as rescue therapy in refractory myasthenic crisis. Neurol Sci 2023; 44:3707-3709. [PMID: 37306795 DOI: 10.1007/s10072-023-06900-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/03/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Myasthenia gravis is a long-lasting autoimmune neuromuscular disease caused by antibodies attacking the neuromuscular junction, which can result in muscle weakness, fatigue, and respiratory failure in severe cases. Myasthenic crisis is a life-threatening event that requires hospitalization and treatments with intravenous immunoglobulin or plasma exchange. We reported the case of an AChR-Ab-positive myasthenia gravis patient with refractory myasthenic crisis, in which starting eculizumab as rescue therapy led to a complete resolution of the acute neuromuscular condition. CASE PRESENTATION A 74-year-old man diagnosed with myasthenia gravis. ACh-receptor antibodies positivity comes to our observation for a recrudescence of symptoms, unresponsive to conventional rescue therapies. Due to the clinical worsening over the following weeks, the patient was admitted to intensive care unit, where he underwent therapy with eculizumab. About 5 days after the treatment, there was a significant and complete recovery of clinical condition with weaning-off from invasive ventilation and discharge to outpatient regimen, with reduction of steroid intake and biweekly maintenance with eculizumab. DISCUSSION Eculizumab, a humanized monoclonal antibody that inhibits complement activation, is now approved as treatment for refractory generalized myasthenia gravis with anti-AChR antibodies. The use of eculizumab in myasthenic crisis is still investigational, but this case report suggests that it may be a promising treatment option for patients with severe clinical condition. Ongoing clinical trials will be needed to further evaluate the safety and efficacy of eculizumab in myasthenic crisis.
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Affiliation(s)
- Claudia Vinciguerra
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy.
| | - Liliana Bevilacqua
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy
| | - Antonella Toriello
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy
| | - Aniello Iovino
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy
| | - Giuseppe Piscosquito
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy
| | - Giuseppe Calicchio
- Anesthesia and Intensive Care Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Paolo Barone
- Neurology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Largo Città di Ippocrate, 84100, Salerno, Italy
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Tavee J, Brannagan TH, Lenihan MW, Muppidi S, Kellermeyer L, D Donofrio P. Updated consensus statement: Intravenous immunoglobulin in the treatment of neuromuscular disorders report of the AANEM ad hoc committee. Muscle Nerve 2023; 68:356-374. [PMID: 37432872 DOI: 10.1002/mus.27922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/05/2023] [Indexed: 07/13/2023]
Abstract
Intravenous immune globulin (IVIG) is an immune-modulating biologic therapy that is increasingly being used in neuromuscular disorders despite the paucity of high-quality evidence for various specific diseases. To address this, the AANEM created the 2009 consensus statement to provide guidance on the use of IVIG in neuromuscular disorders. Since then, there have been several randomized controlled trials for IVIG, a new FDA-approved indication for dermatomyositis and a revised classification system for myositis, prompting the AANEM to convene an ad hoc panel to update the existing guidelines.New recommendations based on an updated systemic review of the literature were categorized as Class I-IV. Based on Class I evidence, IVIG is recommended in the treatment of chronic inflammatory demyelinating polyneuropathy, Guillain-Barré Syndrome (GBS) in adults, multifocal motor neuropathy, dermatomyositis, stiff-person syndrome and myasthenia gravis exacerbations but not stable disease. Based on Class II evidence, IVIG is also recommended for Lambert-Eaton myasthenic syndrome and pediatric GBS. In contrast, based on Class I evidence, IVIG is not recommended for inclusion body myositis, post-polio syndrome, IgM paraproteinemic neuropathy and small fiber neuropathy that is idiopathic or associated with tri-sulfated heparin disaccharide or fibroblast growth factor receptor-3 autoantibodies. Although only Class IV evidence exists for IVIG use in necrotizing autoimmune myopathy, it should be considered for anti-hydroxy-3-methyl-glutaryl-coenzyme A reductase myositis given the risk of long-term disability. Insufficient evidence exists for the use of IVIG in Miller-Fisher syndrome, IgG and IgA paraproteinemic neuropathy, autonomic neuropathy, chronic autoimmune neuropathy, polymyositis, idiopathic brachial plexopathy and diabetic lumbosacral radiculoplexopathy.
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Affiliation(s)
- Jinny Tavee
- National Jewish Health, Division of Neurology, Denver, Colorado, USA
| | - Thomas H Brannagan
- Vagelos College of Physicians and Surgeons, Neurological Institute, Columbia University, New York, New York, USA
| | | | - Sri Muppidi
- Stanford Neuroscience Health Center, Palo Alto, California, USA
| | | | - Peter D Donofrio
- Neurology Clinic, Vanderbilt University, Nashville, Tennessee, USA
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Zhu Y, Wang B, Hao Y, Zhu R. Clinical features of myasthenia gravis with neurological and systemic autoimmune diseases. Front Immunol 2023; 14:1223322. [PMID: 37781409 PMCID: PMC10538566 DOI: 10.3389/fimmu.2023.1223322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/23/2023] [Indexed: 10/03/2023] Open
Abstract
Multiple reports on the co-existence of autoimmune diseases and myasthenia gravis (MG) have raised considerable concern. Therefore, we reviewed autoimmune diseases in MG to explore their clinical presentations and determine whether the presence of autoimmune diseases affects the disease severity and treatment strategies for MG. We reviewed all the major immune-mediated coexisting autoimmune conditions associated with MG. PubMed, Embase and Web of Science were searched for relevant studies from their inception to January 2023. There is a higher frequency of concomitant autoimmune diseases in patients with MG than in the general population with a marked risk in women. Most autoimmune comorbidities are linked to AChR-MG; however, there are few reports of MuSK-MG. Thyroid disorders, systemic lupus erythematosus, and vitiligo are the most common system autoimmune diseases associated with MG. In addition, MG can coexist with neurological autoimmune diseases, such as neuromyelitis optica (NMO), inflammatory myopathy (IM), multiple sclerosis (MS), and autoimmune encephalitis (AE), with NMO being the most common. Autoimmune diseases appear to develop more often in early-onset MG (EOMG). MS coexists more commonly with EOMG, while IM coexists with LOMG. In addition, MG complicated by autoimmune diseases tends to have mild clinical manifestations, and the coexistence of autoimmune diseases does not influence the clinical course of MG. The clinical course of neurological autoimmune diseases is typically severe. Autoimmune diseases occur most often after MG or as a combined abnormality; therefore, timely thymectomy followed by immunotherapy could be effective. In addition, thymoma-associated AChR MG is associated with an increased risk of AE and IM, whereas NMO and MS are associated with thymic hyperplasia. The co-occurrence of MG and autoimmune diseases could be attributed to similar immunological mechanisms with different targets and common genetic factor predisposition. This review provides evidence of the association between MG and several comorbid autoimmune diseases.
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Affiliation(s)
| | | | | | - Ruixia Zhu
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
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Harrison A, Mudhar O, Yoo J, Rampal M. Diplopia in a patient presenting with "blurred vision": a case report. J Med Case Rep 2023; 17:402. [PMID: 37679826 PMCID: PMC10485954 DOI: 10.1186/s13256-023-04089-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/18/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Myasthenia gravis is an autoimmune condition affecting the neuromuscular junction and causing muscle weakness along with fatigue (myasthenia). When the clinical manifestations of myasthenia gravis are isolated to the eye muscles, only causing weak eye movements, it is referred to as ocular myasthenia gravis, which can mimic a 1 and ½ syndrome. CASE PRESENTATION An African-American female in her fifties with past medical history of hypertension presented to our outpatient clinic with complaints of blurred vision for two weeks. Her symptoms were associated with facial discomfort and a generalized headache. On physical examination upon her initial presentation, there was demonstratable swelling of the left upper eyelid with drooping. Her extraocular movements revealed defects with the abduction and adduction of the right eye, and the left eye would not adduct, although the outward movement was normal. The left eye failed to lift/elevate completely when looking upwards, a pseudo 1 and ½ syndrome. A positive Cogan lid twitch was also noticed. Imaging of the brain and orbit ruled out central causes. Diagnosis of ocular myasthenia gravis was made in accordance with positive anti-acetylcholine receptor antibodies. With 120 mg pyridostigmine oral dose, the patient experienced improvement subjectively and objectively, and the patient was discharged on oral pyridostigmine and prednisone. Six months later, with prednisone having been tapered off, the patient developed a myasthenic crisis and was treated with plasmapheresis and intravenous immunoglobulins. After recovering from the myasthenic crisis, efgartigimod infusions were instituted, which helped our patient restore normal life. CONCLUSION Our patient who presented with "blurred vision" was discovered to have binocular diplopia due to significant dysconjugate eye movements. After diligently ruling out central etiologies, we concluded that her presentation was due to a peripheral etiology. Her serologies and her presentation helped confirm a diagnosis of ocular myasthenia gravis. Also, as in most cases, our patient also progressed to develop generalized myasthenia gravis while on pyridostigmine. Efgartigimod infusions instituted after our patient recovered from a myasthenic crisis have helped her restore a normal life.
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Affiliation(s)
- Anil Harrison
- Department of Internal Medicine, UCF/HCA, Pensacola, FL, USA
| | - Onkar Mudhar
- Internal Medicine Resident, Department of Internal Medicine, Touro University, Stockton, CA, USA
| | - Jun Yoo
- Department of Internal Medicine, UCF/HCA, Pensacola, FL, USA.
| | - Mayank Rampal
- Department of Internal Medicine, UCF/HCA, Pensacola, FL, USA
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Ristovska S, Stomnaroska O, Dimitrioska R. Transient Neonatal Myasthenia Gravis: A Case Report. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2023; 44:165-169. [PMID: 37453109 DOI: 10.2478/prilozi-2023-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Transient neonatal myasthenia gravis (TNMG) is a neuromuscular disorder that occurs in infants born from mothers with myasthenia gravis (MG) due to transplacental transfer of antibodies against the acetylcholine receptor. TNMG is a rare form occurring in 10-15% of infants born from mothers with MG. We present a case of a newborn with TNMG with generalized hypotonia and respiratory distress. The newborn shows symptoms of hypotonia, weakened reflexes, poor crying, difficult sucking and potentiated tachydyspnea after 24 hours of birth and needs of assisted mechanical ventilation. Based on the mother's positive history of MG and the high titer of mother's (8.43nmol/l) and newborn's (9.088nmol/l) anti-AChR antibodies, TNMG was diagnosed. The baby was treated with assisted mechanical ventilation and neostig-mine until the anti-AChR antibody titer was negative. Adequate management of the newborn resulted in a positive outcome and evident withdrawal of the symptoms. Although TNMG is one of the rare neuromuscular disorders in newborns that can be treated, a multidisciplinary approach in the management of pregnant women with MG and newborns through timely diagnosis and early appropriate treatment, results in successful resolution of this condition.
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Affiliation(s)
- Sanja Ristovska
- 1PJU University Clinic for Gynecology and Obstetrics, Faculty of Medicine, University "St. Cyril and Methodius", Skopje
| | - Orhideja Stomnaroska
- 1PJU University Clinic for Gynecology and Obstetrics, Faculty of Medicine, University "St. Cyril and Methodius", Skopje
| | - Renata Dimitrioska
- 1PJU University Clinic for Gynecology and Obstetrics, Faculty of Medicine, University "St. Cyril and Methodius", Skopje
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Dalakas MC. Advances in the therapeutic algorithm for myasthenia gravis. Nat Rev Neurol 2023; 19:393-394. [PMID: 37253854 DOI: 10.1038/s41582-023-00825-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
- Neuroimmunology Unit, National and Kapodistrian University, University of Athens Medical School, Athens, Greece.
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Meisel A. Are CAR T cells the answer to myasthenia gravis therapy? Lancet Neurol 2023; 22:545-546. [PMID: 37353270 DOI: 10.1016/s1474-4422(23)00211-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023]
Affiliation(s)
- Andreas Meisel
- Neuroscience Clinical Research Center, Center for Stroke Research Berlin, and Department of Neurology with Experimental Neurology, Charité Universitaetsmedizin Berlin, Charitéplatz 1, D-10117 Berlin, Germany.
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Yang J, Wu J, Han T, Lu H, Li F, Li L, Su S, Jiang P, Hou Z. Global research hotspots and frontiers of myasthenia gravis from 2002 to 2021: A bibliometric study. Medicine (Baltimore) 2023; 102:e34002. [PMID: 37327308 PMCID: PMC10270528 DOI: 10.1097/md.0000000000034002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/24/2023] [Indexed: 06/18/2023] Open
Abstract
The objective of this study is to utilize bibliometric and visual analysis techniques to identify hotspots and frontiers of research in myasthenia gravis (MG) and provide valuable references for future research. The Web of Science Core Collection (WoSCC) database was used to retrieve literature data related to MG research, which was then analyzed using VOSviewer 1.6.18, CiteSpace 6.1.R3, and the Online Platform for Bibliometric Analysis. The analysis revealed 6734 publications distributed across 1612 journals and contributed by as many as 24,024 authors affiliated with 4708 institutions across 107 countries/regions. The number of annual publications and citations for MG research has steadily increased over the past 2 decades, with the last 2 years alone witnessing a remarkable increase in annual publications and citations to over 600 and 17,000, respectively. In terms of productivity, the United States emerged as the top producing country, while the University of Oxford ranked first in terms of research institutions. Vincent A was identified as the top contributor in terms of publications and citations. Muscle & Nerve and Neurology ranked first in publications and citations respectively, with clinical neurology and neurosciences among the main subject categories explored. The study also identified pathogenesis, eculizumab, thymic epithelial cells, immune checkpoint inhibitors, thymectomy, MuSK antibodies, risk, diagnosis, and management as the current hot research topics in MG, while burst keywords like quality of life, immune-related adverse events (irAEs), rituximab, safety, nivolumab, cancer, and classification indicated the frontiers of MG research. This study effectively identifies the hotspots and frontiers of MG research, and offers valuable references for researchers interested in this area.
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Affiliation(s)
- Jiali Yang
- Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
| | - Jiaojiao Wu
- Xiangyu Pharmaceutical Co., Ltd., Linyi, China
| | - Tingliang Han
- Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
| | - Hua Lu
- Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
| | - Fangcun Li
- Guilin Municipal Hospital of Traditional Chinese Medicine, Guilin, China
| | - Leilei Li
- Guangxi University of Chinese Medicine, Nanning, China
| | - Shaoting Su
- Guangxi University of Chinese Medicine, Nanning, China
| | - Ping Jiang
- Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhaomeng Hou
- Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
- Guangxi University of Chinese Medicine, Nanning, China
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Sanders DB, Lutz MW, Raja SM, Juel VC, Guptill JT, Hobson-Webb LD, Massey JM. The Duke Myasthenia Gravis Clinic Registry: II. Analysis of outcomes. Muscle Nerve 2023; 67:291-296. [PMID: 36734303 DOI: 10.1002/mus.27794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION/AIMS The Duke Myasthenia Gravis (MG) Clinic Registry contains comprehensive physician-derived data on patients with MG seen in the Duke MG Clinic since 1980. The aim of this study was to report outcomes in patients seen in the clinic and treated according to the International Consensus Guidance statements. METHODS This is a retrospective cohort study of patients initially seen after 2000 and followed for at least 2 years in the clinic. Treatment goal (TG) was defined as achieving MGFA post-intervention status of "minimal manifestations" or better; PIS was determined by the treating neurologist. Time-to-event analysis, including Cox proportional hazards modeling, was performed to assess the effect of sex, acetylcholine receptor antibody (AChR-Ab) status, age at disease onset, distribution (ocular vs generalized), thymectomy, and thymoma on the time to achieve TG. RESULTS Among the 367 cohort patients, 72% achieved TG (median time less than 2 years). A greater proportion of patients with AChR-Abs and thymectomy achieved TG and they did so sooner than patients without these antibodies or thymectomy. Otherwise, there were no significant differences in these findings within the tested subgroups. The disease duration at the first Duke Clinic visit was shorter in patients who achieved TG than in those who did not. DISCUSSION These results demonstrate outcomes that can be achieved in patients with MG treated according to the current Consensus Guidance statements. Among other things, they can be used to determine the added value and potential role of new treatment modalities developed since 2018.
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Affiliation(s)
- Donald B Sanders
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Michael W Lutz
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Shruti M Raja
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Vern C Juel
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey T Guptill
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Lisa D Hobson-Webb
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Janice M Massey
- Neuromuscular Division, Department of Neurology, Duke University Medical Center, Durham, North Carolina
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Tang YL, Ruan Z, Su Y, Guo RJ, Gao T, Liu Y, Li HH, Sun C, Li ZY, Chang T. Clinical Characteristics and Prognosis of Very late-onset Myasthenia Gravis in China. Neuromuscul Disord 2023; 33:358-366. [PMID: 36990040 DOI: 10.1016/j.nmd.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
Alteration in onset-age distribution in myasthenia gravis (MG) and its increasing prevalence among the elderly underscores the need for a better understanding of the clinical course of MG and the establishment of personalized treatment. In this study we reviewed the demographics, clinical profile, and treatment of MG. Based on onset age, eligible patients were classified as early-onset MG (onset age ≥18 and <50 years), late-onset MG (onset age ≥50 and <65 years), and very late-onset MG (onset age ≥65 years). Overall, 1160 eligible patients were enrolled. Patients with late- and very late-onset MG showed a male predominance (P=0.02), ocular MG subtype (P=0.001), and seropositivity for acetylcholine receptors and titin antibodies (P<0.001). In very late-onset MG, a lower proportion of patients retained minimal manifestations status or better, a higher proportion of patients had MG-related deaths (P<0.001), and a shorter maintenance time of minimal manifestation status or better was seen at the last follow-up (P=0.007) than that in patients with early- and late-onset MG. Non-immunotherapy may associated with a poor prognosis in patients in the very late-onset group. Further studies on very late-onset MG patients should be performed to evaluate the relationship between immunotherapy and prognosis.
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Affiliation(s)
- Yong-Lan Tang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China.
| | - Yue Su
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Rong-Jing Guo
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Ting Gao
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Yu Liu
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Huan-Huan Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Chao Sun
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China
| | - Zhu-Yi Li
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China.
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, The Fourth Military Medical University, Xi'an 710038, China.
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43
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Salort-Campana E. [Myasthenia]. Rev Prat 2023; 73:305-306. [PMID: 37289123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Emmanuelle Salort-Campana
- Centre de référence des maladies neuromusculaires et de la sclérose latérale amyotrophique, hôpital La Timone, Marseille, France. Association française contre les myopathies(AFM)
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Mandell BF. Myasthenia gravis: An update for internists. Cleve Clin J Med 2023; 90:72-73. [PMID: 36724915 DOI: 10.3949/ccjm.90b.02023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Martín Pérez SE, Martín Pérez IM, Sánchez-Romero EA, Sosa Reina MD, Muñoz Fernández AC, Alonso Pérez JL, Villafañe JH. Percutaneous Electrical Nerve Stimulation (PENS) for Infrapatellar Saphenous Neuralgia Management in a Patient with Myasthenia gravis (MG). Int J Environ Res Public Health 2023; 20:2617. [PMID: 36767982 PMCID: PMC9915414 DOI: 10.3390/ijerph20032617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/24/2023] [Accepted: 01/29/2023] [Indexed: 06/18/2023]
Abstract
Myasthenia gravis is a neuromuscular transmission disorder characterized by weakness of the cranial and skeletal muscles, however, neuropathies are extremely rare. In this case report we present a case of a 61-year-old man diagnosed Myasthenia gravis who came to our attention due to a 1 week of acute deep pain [NPRS 8/10] in the anterior and medial right knee which occurred during walking [NPRS 8/10] or stair climbing [NPRS 9/10]. A complete medical record and clinical examination based on physical exploration and ultrasound assessment confirmed a infrapatellar saphenous neuralgia. Therapeutic interventions included Percutaneous nerve electrical stimulation combined with pain neuroscience education, neural mobilization of the saphenous nerve and quadriceps resistance exercises. After 4 weeks, pain intensity [NRPS = 1/10], knee functionality [OKS = 41/48] and lower limb functionality [LLFI = 80%] were notably improved, nevertheless, fatigue [RPE = 2/10] was similar than baseline. At 2 months of follow-up, the effect on intensity of pain NRPS [0/10] and functionality OKS [40/48] and LLFI [82%] was maintained, however, no significant clinical changes were detected on perceived fatigue RPE Scale [2/10]. Despite the important methodological limitations of this study, our case report highlights the efficacy of percutaneous electrical nerve stimulation combined with physical agents modalities for pain and functionality of infrapatellar saphenous neuralgia in the context of Myasthenia gravis.
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Affiliation(s)
- Sebastián Eustaquio Martín Pérez
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea de Canarias, 38300 Santa Cruz de Tenerife, Spain
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
- Departamento de Farmacología y Medicina Física, Área de Radiología y Medicina Física, Secciones de Enfermería y Fisioterapia, Facultad de Ciencias de la Salud, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain
- Escuela de Doctorado y Estudios de Posgrado, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain
| | - Isidro Miguel Martín Pérez
- Departamento de Farmacología y Medicina Física, Área de Radiología y Medicina Física, Secciones de Enfermería y Fisioterapia, Facultad de Ciencias de la Salud, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain
- Escuela de Doctorado y Estudios de Posgrado, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain
| | - Eleuterio A. Sánchez-Romero
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea de Canarias, 38300 Santa Cruz de Tenerife, Spain
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
- Physiotherapy and Orofacial Pain Working Group, Sociedad Española de Disfunción Craneomandibular y Dolor Orofacial (SEDCYDO), 28009 Madrid, Spain
| | - María Dolores Sosa Reina
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
| | - Alberto Carlos Muñoz Fernández
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
| | - José Luis Alonso Pérez
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea de Canarias, 38300 Santa Cruz de Tenerife, Spain
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
- Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
- Onelife Center, Multidisciplinary Pain Treatment Center, 28925 Alcorcón, Spain
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Meisel A, Baggi F, Behin A, Evoli A, Kostera-Pruszczyk A, Mantegazza R, Morales RJ, Punga AR, Sacconi S, Schroeter M, Verschuuren J, Crathorne L, Holmes K, Leite MI. Role of autoantibody levels as biomarkers in the management of patients with myasthenia gravis: A systematic review and expert appraisal. Eur J Neurol 2023; 30:266-282. [PMID: 36094738 DOI: 10.1111/ene.15565] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/26/2022] [Accepted: 09/04/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Although myasthenia gravis (MG) is recognized as an immunoglobulin G autoantibody-mediated disease, the relationship between autoantibody levels and disease activity in MG is unclear. We sought to evaluate this landscape through systematically assessing the evidence, testing the impact of predefined variables on any relationship, and augmenting with expert opinion. METHODS In October 2020, a forum of leading clinicians and researchers in neurology from across Europe (Expert Forum for Rare Autoantibodies in Neurology in Myasthenia Gravis) participated in a series of virtual meetings that took place alongside the conduct of a systematic literature review (SLR). RESULTS Forty-two studies were identified meeting inclusion criteria. Of these, 10 reported some correlation between a patient's autoantibody level and disease severity. Generally, decreased autoantibody levels (acetylcholine receptor, muscle-specific kinase, and titin) were positively and significantly correlated with improvements in disease severity (Quantitative Myasthenia Gravis score, Myasthenia Gravis Composite score, Myasthenia Gravis Activities of Daily Living score, Myasthenia Gravis Foundation of America classification). Given the limited evidence, testing the impact of predefined variables was not feasible. CONCLUSIONS This first SLR to assess whether a correlation exists between autoantibody levels and disease activity in patients with MG has indicated a potential positive correlation, which could have clinical implications in guiding treatment decisions. However, in light of the limited and variable evidence, we cannot currently recommend routine clinical use of autoantibody level testing in this context. For now, patient's characteristics, clinical disease course, and laboratory data (e.g., autoantibody status, thymus histology) should inform management, alongside patient-reported outcomes. We highlight the need for future studies to reach more definitive conclusions on this relationship.
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Affiliation(s)
- Andreas Meisel
- Department of Neurology, Integrated Myasthenia Gravis Center, NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fulvio Baggi
- Neuroimmunology and Neuromuscular Diseases Unit, Scientific Institute for Research and Health Care Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Anthony Behin
- Department of Neuromyology, Pitié-Salpêtrière Hospital, Public Hospital Network of Paris, Institute of Myology, Paris, France
| | - Amelia Evoli
- Catholic University of the Sacred Heart and Agostino Gemelli University Polyclinic Foundation, Scientific Institute for Research and Health Care, Rome, Italy
| | | | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Scientific Institute for Research and Health Care Foundation Carlo Besta Neurological Institute, Milan, Italy
| | | | - Anna Rostedt Punga
- Department of Medical Science, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | | | - Michael Schroeter
- Department of Neurology, University Hospital Cologne, Cologne, Germany
| | - Jan Verschuuren
- Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Maria-Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Sanadze AG, Sidnev DV, Tumurov DA, Afanasieva OI. [Ocular myasthenia gravis]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:116-120. [PMID: 37796078 DOI: 10.17116/jnevro2023123091116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
The article describes an urgent medical and social problem - the diagnosis and treatment of the ocular myasthenia gravis. Despite recent advances in the study of synaptic pathology, the diagnosis of the ocular form of myasthenia gravis remains a challenging problem. This is due to the poor information content of laboratory and electromyographic methods in the diagnosis of ocular myasthenia gravis, and the generalized myasthenia gravis manifests in 90% of cases by external ophthalmoplegia and ptosis. The article highlights the features of the diagnosis and differential diagnosis of ocular myasthenia gravis. Data on the course and features of the clinical presentation of the disease are presented. The importance of analyzing anamnestic data and clinical manifestations of the disease is emphasized. The article discusses modern approaches to the treatment of the ocular myasthenia gravis. The authors present clinical observations of 2 patients with ocular myasthenia gravis.
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Affiliation(s)
- A G Sanadze
- Buyanov City Clinical Hospital, Moscow, Russia
- Scientific and Practical Psychoneurological Center, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - D V Sidnev
- Scientific and Practical Psychoneurological Center, Moscow, Russia
| | - D A Tumurov
- Buyanov City Clinical Hospital, Moscow, Russia
- Scientific and Practical Psychoneurological Center, Moscow, Russia
- Pirogov Russian National Research Medical University, Moscow, Russia
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Abstract
Myasthenia gravis is an autoimmune disorder caused by antibodies against elements in the postsynaptic membrane at the neuromuscular junction, which leads to muscle weakness. Congenital myasthenic syndromes are rare and caused by mutations affecting pre- or postsynaptic function at the neuromuscular synapse and resulting in muscle weakness. MG has a prevalence of 150-250 and an annual incidence of 8-10 individuals per million. The majority has disease onset after age 50 years. Juvenile MG with onset in early childhood is more common in East Asia. MG is subgrouped according to type of pathogenic autoantibodies, age of onset, thymus pathology, and generalization of muscle weakness. More than 80% have antibodies against the acetylcholine receptor. The remaining have antibodies against MuSK, LRP4, or postsynaptic membrane antigens not yet identified. A thymoma is present in 10% of MG patients, and more than one-third of thymoma patients develop MG as a paraneoplastic condition. Immunosuppressive drug therapy, thymectomy, and symptomatic drug therapy with acetylcholine esterase inhibitors represent cornerstones in the treatment. The prognosis is good, with the majority of patients having mild or moderate symptoms only. Most congenital myasthenic syndromes are due to dysfunction in the postsynaptic membrane. Symptom debut is in early life. Symptomatic drug treatment has sometimes a positive effect.
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Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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Li HY, Shao LY, Song M, Hu SM, Yue YX, Li HF. Safety of inactivated SARS-CoV-2 vaccines in myasthenia gravis: A survey-based study. Front Immunol 2022; 13:923017. [PMID: 35990671 PMCID: PMC9388926 DOI: 10.3389/fimmu.2022.923017] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Vaccination remains the most effective measure to prevent SARS-CoV-2 infection and worse outcomes. However, many myasthenia gravis (MG) patients are hesitant to receive vaccine due to fear of worsening. Methods MG patients were consecutively enrolled in two MG centers in North China. The “worsening” after vaccination was self-reported by MG patients, and severity was measured with a single simple question. The general characteristics and disease status immediately prior to the first dose were compared between the worsening and non-worsening groups. Independent factors associated with worsening were explored with multivariate regression analysis. Results One hundred and seven patients were included. Eleven patients (10.3%) reported worsening after vaccination, including eight patients with mild or moderate worsening and three patients with severe worsening. Only one of them (0.9%) needed an escalation of immunosuppressive treatments. There were significant differences between the worsening and non-worsening groups in terms of Myasthenia Gravis Foundation of America classes immediately before the first dose and intervals since the last aggravation. Precipitating factors might contribute to the worsening in some patients. Logistic regression revealed that only interval since the last aggravation ≤6 months was associated with worsening after SARS-CoV-2 vaccination (P = 0.01, OR = 8.62, 95% CI: 1.93–38.46). Conclusion SARS-CoV-2 vaccines (an overwhelming majority were inactivated vaccines) were found safe in milder Chinese MG patients who finished two doses. Worsening after vaccination was more frequently seen in patients who were presumed as potentially unstable (intervals since last aggravation ≤6 months). However, mild worsening did occur in patients who were presumed to be stable. Precipitating factors should still be sought and treated for better outcome.
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Affiliation(s)
- Hong-Yan Li
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Li-Yuan Shao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Min Song
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| | - Shi-Min Hu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yao-Xian Yue
- Department of Neurology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
- *Correspondence: Yao-Xian Yue, ; Hai-Feng Li,
| | - Hai-Feng Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Yao-Xian Yue, ; Hai-Feng Li,
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Fujita N, Ishikura T, Nagashima N, Nishikawa A, Sumi-Akamaru H, Naka T. [Rippling muscle disease with myasthenia gravis]. Rinsho Shinkeigaku 2022; 62:563-566. [PMID: 35753788 DOI: 10.5692/clinicalneurol.cn-001742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In February 2020, a 51-year-old woman experienced leg myalgia and noticed calf muscle movements that resembled a rippling wave while crouching down. In June 2020, she complained of bilateral arm myalgia. In August 2020, she developed left ptosis, had difficulty raising her bilateral arms, and developed diplopia and was admitted to our hospital. Anti-acetylcholine receptor antibodies turned out to be positive. We made a diagnosis of myasthenia gravis and acquired rippling muscle disease (RMD). Her myasthenia gravis symptoms and myalgia decreased with oral prednisolone. Contrast-enhanced computed tomography revealed thymoma. She underwent extended thymectomy and was discharged from the hospital. Her myalgia worsened, but it was responsive to methylprednisolone pulse therapy. CAV3 gene mutations are recognized as causes of congenial RMD whereas acquired RMD is associated with myasthenia gravis. Acquired RMD is rarely reported in Japan, but should be kept in mind as a condition treatable with immunotherapy.
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Affiliation(s)
- Naohiro Fujita
- Department of Neurology, Higashiosaka City Medical Center
| | | | | | | | | | - Takashi Naka
- Department of Neurology, Higashiosaka City Medical Center
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