Myasthenial gravis; problems in diagnosis

The possibility of myasthenia gravis must be considered in patients persistently complaining of weakness and fatigue. There may be many difficulties and pitfalls in differentiating myasthenia gravis from other disorders in which muscular weakness is a common complaint. Observation of a group of 36 patients with myasthenia gravis, and another group of 30 cases involving the differential diagnosis of myasthenia gravis, led to a conclusion that a physician should apply criteria carefully before arriving at a diagnosis of myasthenia gravis and instituting drug therapy, since nonmyasthenics may frequently respond with subjective improvement temporarily following administration of cholinergic drugs.Myasthenia gravis may be a more common disorder than was suspected in the past.     

Myasthenia Gravis,Autoantibodies, and HL-A Antigens

The serum of 100 patients with myasthenia gravis and 441 of their first-degree relatives was studied for the presence of autoantibodies against several antigens. Antibodies to skeletal muscle were present in 22% of the patients and in 2% of the relatives. Both these frequencies were significantly higher than those in matched control subjects. Also, antinuclear antibodies were present more often both in the patients and in the relatives. Typing for HL-A antigens had shown a positive correlation between HL-A 8 and myasthenia gravis which was significantly higher in women than in men. Antibodies to skeletal muscle and thymomas were found to be much rarer in HL-A 8-positive patients than in HL-A 8-negative patients; HL-A 8-positive patients acquired the disease at an earlier age.HL-A 2-positive patients more often had thymomas and antibodies to skeletal muscle than HL-A 2-negative patients; HL-A 2-positive patients acquired myasthenia gravis at a later age.The fact that the clinical aspects of the HL-A 8-negative and HL-A 2-positive patients were different from those of the HL-A 8-positive and HL-A 2-negative patients justifies the hypothesis that there are two forms of myasthenia gravis.     

Prospects for specific immunotherapy in myasthenia gravis

Myasthenia gravis is an autoimmune disease resulting from a breakdown in T and B cell tolerance to acetylcholine receptor (AChR). Autoantibodies to AChR mediate the disease. Recent advances in experimental immunotherapy of autoimmune disease provide several possibilities for specific intervention in this well-characterized condition.     

Control of the autoimmune response by type 2 nitric oxide synthase

Immune defense against pathogens often requires NO, synthesized by type 2 NO synthase (NOS2). To discern whether this axis could participate in an autoimmune response, we immunized NOS2-deficient mice with the autoantigen acetylcholine receptor, inducing muscle weakness characteristic of myasthenia gravis, a T cell-dependent Ab-mediated autoimmune disease. We found that the acetylcholine receptor-immunized NOS2-deficient mice developed an exacerbated form of myasthenia gravis, and demonstrated that NOS2 expression limits autoreactive T cell determinant spreading and diversification of the autoantibody repertoire, a process driven by macrophages. Thus, NOS2/NO is important for silencing autoreactive T cells and may restrict bystander autoimmune reactions following the innate immune response.     

Prenatal diagnosis of genodermatoses by ultrastructural diagnostic markers in extra-embryonic tissues: defective hemidesmosomes in amnion epithelium of fetuses affected with epidermolysis bullosa Herlitz type (an alternative prenatal diagnosis in certain cases)

Summary We report the first use of amnion epithelium for prenatal diagnosis. Prenatal diagnosis of recessive epidermolysis bullosa atrophicans generalisata gravis Herlitz type can at present be achieved with safety by detailed ultrastructural analysis of fetal skin. Because of the close developmental origin of amnion and skin, which has been elucidated by the recent development of antiamnion antibodies against dermo-epidermal junction antigens and by their abnormal binding in epidermolysis bullosa skin, there is presumably some morphological relationship between amnion epithelium and skin. In a comparative study of extra-embryonic tissues, we found ultrastructurally complete hemidesmosomes in all 24 investigated normal amnion samples from gestational weeks 15–27, but not in 7 reflected chorion samples from weeks 16–22. The results of placental chorion samples were not reliable. Amnion of 5 fetuses affected with epidermolysis bullosa atrophicans generalisata gravis revealed only hypoplastic hemidesmosomes, the same defect as in the respective skin. In a recent case where unfortunately only non-skin material was available, a positive prenatal diagnosis of epidermolysis bullosa atrophicans gravis Herlitz was performed from the amnion material. The diagnosis was confirmed by investigation of the fetal skin after termination. Investigation of amnion membranes is therefore an alternative for prenatal diagnosis of epidermolysis bullosa atrophicans gravis Herlitz in certain cases. The possibility and limitations of the general use of amnion for prenatal diagnosis are discussed.     

Autoimmune disease and the nervous system. Biochemical,molecular, and clinical update.

Autoimmunity in the central and peripheral nervous system can manifest as the result of cellular or humoral immune responses to autoantigens. There is evidence that multiple sclerosis is a cell-mediated autoimmune disease of the central nervous system in which both myelin and the cell that produces the myelin are destroyed. Diseases such as acute inflammatory demyelinating polyneuropathy (also called Guillain-Barré syndrome) and myasthenia gravis are considered antibody-mediated diseases of the peripheral nervous system and neuromuscular junctions, respectively. We review these diseases and explore mechanisms of immune-mediated destruction of these nervous system components. We specifically focus on one effective therapy aimed at countering the immune attack, that of thymectomy in patients with myasthenia gravis.     

Amelioration of experimental autoimmune myasthenia gravis in rats by neonatal FcR blockade

The neonatal FcR (FcRn) plays a critical role in IgG homeostasis by protecting it from a lysosomal degradation pathway. It has been shown that IgG has an abnormally short half-life in FcRn-deficient mice and that FcRn blockade significantly increases the catabolism of serum IgG in mice. Therefore, reduction of serum IgG half-life may have therapeutic benefits in Ab-mediated autoimmune diseases. We have studied the therapeutic effects of an anti-rat FcRn mAb, 1G3, in two rat models of myasthenia gravis, a prototypical Ab-mediated autoimmune disease. Passive experimental autoimmune myasthenia gravis was induced by administration of an anti-acetylcholine receptor (AChR) mAb, and it was shown that treatment with 1G3 resulted in dose-dependent amelioration of the disease symptoms. In addition, the concentration of pathogenic Ab in the serum was reduced significantly. The effect of 1G3 was also studied in an active model of experimental autoimmune myasthenia gravis in which rats were immunized with AChR. Treatment with 1G3 significantly reduced the severity of the disease symptoms as well as the levels of total IgG and anti-AChR IgG relative to untreated animals. These data suggest that FcRn blockade may be an effective way to treat Ab-mediated autoimmune diseases.     

Acetylcholinesterase--apoptosis induction, role in neurological diseases and leukemia

Acetylcholinesterase (AChE - EC. 3.1.1.7) plays an essential role in acetylcholine-mediated neurotransmission. Unfortunately, an AChE-peptide exhibits pathophysiological activity via an apoptotic pathway that could play an important role in neuronal development and neurodegeneration. It was found that a peptide derived from AChE may induce neuronal death and acetylcholinesterase may induce neurological changes in the development of Alzheimer's disease. It was also stated that complex of AChE with beta-amyloid is much more toxic than amyloid and causes stronger neurological changes. AChE promotes the generation of amyloid by accelerating the expression of peptide precursor (beta-APP) in glial cells. The essential role is also played by AChE in induction of hematological disease. It is well known that phospho-organic compounds cause inhibition of AChE precursors what is related to decrease of hemoglobin concentration, number of erythrocytes and hematocrit level. The article is an attempt to explain the role of acetylcholinesterase in neuronal apoptosis, Alzheimer's disease and Myasthenia gravis as well as in leukemia.     

Antigenic modulation of junctional acetylcholine receptor is not sufficient to account for the development of myasthenia gravis in receptor immunized mice

Myasthenia gravis (MG) is a disease thought to result from an autoimmune response against the nicotinic acetylcholine receptor of the neuromuscular junction. Although there is little doubt that the muscular weakness characteristic of MG can be attributed to an antibody-mediated reduction in the density of AChR, the mechanism responsible for this reduction remains uncertain. In the present studies we have used a mouse model of MG, termed experimental myasthenia gravis (EMG), to test the possibility that antigenic modulation of AChR may be the principle mechanism whereby this reduction in AChR density is achieved. We found that immunization of mice with AChR, on average, leads to a twofold increase in the rate of junctional AChR degradation. Because this effect occurred to the same extent in mice that developed severe paralysis and in those that gave no indication of muscular weakness, the role of antigenic modulation as a major pathologic mechanism in MG is questioned.     

Ocular myasthenia gravis in a patient with euthyroid Graves' disease

Graves' disease (GD) and ocular myasthenia gravis (OMG) are autoimmune disorders which may occur in the same patient. Myasthenia gravis is 50 times more common in patients with Graves' disease when compared to the normal population. Typically, a patient may be diagnosed with one disorder and have no signs or symptoms of the other, including negative laboratory studies. Therefore, when managing patients with known Graves' disease, it is important to be alert to the possibility of ocular myasthenia.     

IL-1 receptor antagonist-mediated therapeutic effect in murine myasthenia gravis is associated with suppressed serum proinflammatory cytokines, C3, and anti-acetylcholine receptor IgG1

In myasthenia gravis (MG), TNF and IL-1beta polymorphisms and high serum levels of these proinflammatory cytokines have been observed. Likewise, TNF and IL-1beta are critical for the activation of acetylcholine receptor (AChR)-specific T and B cells and for the development of experimental autoimmune myasthenia gravis (EAMG) induced by AChR immunization. We tested the therapeutic effect of human recombinant IL-1 receptor antagonist (IL-1ra) in C57BL/6 mice with EAMG. Multiple daily injections of 0.01 mg of IL-1ra administered for 2 wk following two AChR immunizations decreased the incidence and severity of clinical EAMG. Furthermore, IL-1ra treatment of mice with ongoing clinical EAMG reduced the clinical symptoms of disease. The IL-1ra-mediated suppression of clinical disease was associated with suppressed serum IFN-gamma, TNF-alpha, IL-1beta, IL-2, IL-6, C3, and anti-AChR IgG1 without influencing total serum IgG. Therefore, IL-1ra could be used as a nonsteroidal drug for the treatment of MG.     

Antibodies to an antigen of human thymus epithelial tissue common to the epidermis of the skin in malignant myasthenia]

It has been demonstrated by the indirect immunofluorecent technique that many of the sera of patients with myasthenia gravis react with the anticells of the human thymus epithelial tissue. Sorption of the sera with the suspension of the epidermis cells and the homogenates of the tissues of other human organs showed that the epithelial cell antigen with which the sera of patients with myasthenia reacted were epidermal heteroorganic thymus antigens, i.e. common for the thymus epithelium and skin epidermis. The presence of antibodies to the cells of the epithelial tissue of the thymus in the sera of patients suffering from myasthenia gravis permits to suppose the existence of an immunopathological process against the thymus tissue antigens (including the heteroorganic structures of its epithelium) in this disease.     

The role of acetylcholine receptor antibodies in myasthenia gravis.

Myasthenia gravis is an autoimmune disease of man characterized by remitting and relapsing muscle fatigability. Although the etiology and pathogenesis are incompletely understood, the presence of circulating antibodies directed against the nicotinic acetylcholine (ACh) receptor in 80--90% of patients with myasthenia gravis and the identification of immune complexes at their neuromuscular junction have helped explain the altered neuromuscular transmission. The ACh receptor antibodies do not block access of ACh to the receptor, but do decrease the number of receptors by accelerating their degradation both in rat myotube cultures and in vivo models. In vitro these antibodies play a major role in myasthenia gravis. However, correlations of antibody titers with the clinical state following thymectomy or in neonatal myasthenia suggest that host factors may be equally important in determining whether the ACh receptor antibodies will result in clinical myasthenia.     

Population based study of 12 autoimmune diseases in Sardinia, Italy: prevalence and comorbidity

Background

The limited availability of prevalence data based on a representative sample of the general population, and the limited number of diseases considered in studies about co-morbidity are the critical factors in study of autoimmune diseases. This paper describes the prevalence of 12 autoimmune diseases in a representative sample of the general population in the South of Sardinia, Italy, and tests the hypothesis of an overall association among these diseases.

Methods

Data were obtained from 21 GPs. The sample included 25,885 people. Prevalence data were expressed with 95% Poisson C.I. The hypothesis of an overall association between autoimmune diseases was tested by evaluating the co-occurrence within individuals.

Results

Prevalence per 100,000 are: 552 rheumatoid arthritis, 124 ulcerative colitis, 15 Crohn''s disease, 464 type 1 diabetes, 81 systemic lupus erythematosus, 124 celiac disease, 35 myasthenia gravis, 939 psoriasis/psoriatic arthritis, 35 systemic sclerosis, 224 multiple sclerosis, 31 Sjogren''s syndrome, and 2,619 autoimmune thyroiditis . An overall association between autoimmune disorders was highlighted.

Conclusions

The comparisons with prevalence reported in current literature do not show outlier values, except possibly for a few diseases like celiac disease and myasthenia gravis. People already affected by a first autoimmune disease have a higher probability of being affected by a second autoimmune disorder. In the present study, the sample size, together with the low overall prevalence of autoimmune diseases in the population, did not allow us to examine which diseases are most frequently associated with other autoimmune diseases. However, this paper makes available an adequate control population for future clinical studies aimed at exploring the co-morbidity of specific pairs of autoimmune diseases.     

Serum metabolomics for the diagnosis and classification of myasthenia gravis

Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease with few reliable diagnostic measures. Therefore, it is great important to explore novel tools for the diagnosis of MG. In this study, a serum metabolomic approach based on LC?CMS in combination with multivariate statistical analyses was used to identify and classify patients with various grades of MG. Serum samples from 42 MG patients and 16 healthy volunteers were analyzed by liquid chromatography Fourier transform mass spectrometry (LC-FTMS). MG patients were clearly distinguished from healthy subjects based on their global serum metabolic profiles by using orthogonal partial least squares (OPLS) analysis. Moreover, different changes in metabolic profiles were observed between early- and late-stages MG patients. Nine biomarkers, including gamma-aminobutyric acid and sphingosine 1-phosphate were identified. In addition, 92.8% sensitivity, 83.3% specificity and 90% accuracy were obtained from the OPLS discriminant analysis (OPLS-DA) class prediction model in detecting MG. The results presented here illustrate that serum metabolomics exhibits great potential in the detecting and grading of MG, and it is potentially applicable as a new diagnostic approach for MG.     

Polyacrylamide Gel Electrophoresis of Corynebacterium diphtheriae: a Possible Epidemiological Aid

In this preliminary study, the use of polyacrylamide gel electrophoresis as an aid in the characterization of Corynebacterium diphtheriae was evaluated and a standardized method was developed. The electrophoretic patterns of 17 gravis, 14 mitis, and 2 intermedius types of C. diphtheriae were compared with the electrophoretic patterns of 5 Robinson and Peeney stock gravis serotype strains. Each of the 5 stock serotype strains had different electrophoretic patterns, although some common bands were present. The 17 gravis strains isolated in the United States showed patterns identical to those of the stock gravis serotype II strain. The 14 mitis strains examined produced 6 different electrophoretic patterns, irrespective of geographical location. One mitis pattern corresponded with the pattern of gravis serological type II. The two intermedius strains examined had identical electrophoretic patterns that resembled the pattern of gravis serotype IV. Polyacrylamide gel electrophoresis of C. diphtheriae strains may prove to be a useful epidemiologic tool in establishing the distribution and occurrence of various C. diphtheriae types.     

Suppression of CHRN endocytosis by carbonic anhydrase CAR3 in the pathogenesis of myasthenia gravis

Myasthenia gravis is an autoimmune disorder of the neuromuscular junction manifested as fatigable muscle weakness, which is typically caused by pathogenic autoantibodies against postsynaptic CHRN/AChR (cholinergic receptor nicotinic) in the endplate of skeletal muscle. Our previous studies have identified CA3 (carbonic anhydrase 3) as a specific protein insufficient in skeletal muscle from myasthenia gravis patients. In this study, we investigated the underlying mechanism of how CA3 insufficiency might contribute to myasthenia gravis. Using an experimental autoimmune myasthenia gravis animal model and the skeletal muscle cell C2C12, we find that inhibition of CAR3 (the mouse homolog of CA3) promotes CHRN internalization via a lipid raft-mediated pathway, leading to accelerated degradation of postsynaptic CHRN. Activation of CAR3 reduces CHRN degradation by suppressing receptor endocytosis. CAR3 exerts this effect by suppressing chaperone-assisted selective autophagy via interaction with BAG3 (BCL2-associated athanogene 3) and by dampening endoplasmic reticulum stress. Collectively, our study illustrates that skeletal muscle cell CAR3 is critical for CHRN homeostasis in the neuromuscular junction, and its deficiency leads to accelerated degradation of CHRN and development of myasthenia gravis, potentially revealing a novel therapeutic approach for this disorder.     

Anti-acetylcholine-receptor antibody concentrations after thymectomy in patients with myasthenia gravis.

Serum concentrations of anti-acetylcholine-receptor (anti-AChR) antibody were measured in patients with myasthenia gravis. In those patients undergoing thymectomy concentrations were measured before and after the operation to see whether there might be a connection between the thymus and antibody production. We found no correlation between antibody concentration and either thymectomy or duration and severity of the disease before the operation. Our results suggest that if anti-AChR antibodies are the principal pathogenic factor in myasthenia gravis then immunological and neurophysical variables other than the total serum anti-AChR antibody concentration contribute to the severity of the disease.     

Ocular myasthenia gravis secondary to thymoma

Thymoma is a neoplasm that originates from the epithelial cells of the thymus gland. Approximately 15% of patients with thymoma will present with symptoms of myasthenia gravis (MG),an autoimmune disorder involving the neuromuscular junction. Approximately 50% of patients with symptoms of myasthenia gravis will have thymoma. This paper presents a case report of thymoma and discusses the ocular and systemic manifestations of this uncommon neoplasm. Special emphasis is placed on the association between thymoma and myasthenia gravis.     

Anti-CTLA-4 antibody treatment triggers determinant spreading and enhances murine myasthenia gravis

CTLA-4 appears to be a negative regulator of T cell activation and is implicated in T cell-mediated autoimmune diseases. Experimental autoimmune myasthenia gravis (EAMG), induced by immunization of C57BL/6 mice with acetylcholine receptor (AChR) in adjuvant, is an autoantibody-mediated disease model for human myasthenia gravis (MG). The production of anti-AChR Abs in MG and EAMG is T cell dependent. In the present study, we demonstrate that anti-CTLA-4 Ab treatment enhances T cell responses to AChR, increases anti-AChR Ab production, and provokes a rapid onset and severe EAMG. To address possible mechanisms underlying the enhanced autoreactive T cell responses after anti-CTLA-4 Ab treatment, mice were immunized with the immunodominant peptide alpha(146-162) representing an extracellular sequence of the ACHR: Anti-CTLA-4 Ab, but not control Ab, treatment subsequent to peptide immunization results in clinical EAMG with diversification of the autoantibody repertoire as well as enhanced T cell proliferation against not only the immunizing alpha(146-162) peptide, but also against other subdominant epitopes. Thus, treatment with anti-CTLA-4 Ab appears to induce determinant spreading, diversify the autoantibody repertoire, and enhance B cell-mediated autoimmune disease in this murine model of MG.