MYASTHENIA – DIFFICULTIES IN DIAGNOSTICS AND TREATMENT (CLINICAL CASE ANALYSIS)

  • T. Nehrych Lviv Danylo Halytsky National Medical University, Lviv, Ukraine
  • N. Bozhenko Lviv Danylo Halytsky National Medical University, Lviv, Ukraine
  • S. Kirilyuk Lviv Danylo Halytsky National Medical University, Lviv, Ukraine
Keywords: autoimmune disease, small vessel disease, diabetes mellitus, comorbid diseases

Abstract

Myasthenia gravis is an autoimmune rapidly progressive disease characterized by a neuromuscular disorder due to the formation of autoantibodies to different epitopes of the peripheral neuromuscular device and is clinically manifested by pathological muscle fatigue and weakness. Diagnosis of myasthenia in the elderly is very problematic because doctors regard muscle weakness at this age as a symptom of other diseases. In addition, it may be combined with various pathological conditions. The article describes the presence of comorbid states in patients with myasthenia who were treated at the neurological department of Lviv regional clinical hospital in 2016-2018. 58% of patients with myasthenia, mainly older people, had comorbid diseases. Hypertensive heart disease (34%), ischemic heart disease (20%), diabetes mellitus (12%,) and small brain vessels disease (8%) were frequently observed. A case of late diagnosed generalized myasthenia in a 66-year-old woman with concomitant small vessels disease of the brain and diabetes mellitus is described. The patient was treated at the neurological department of Lviv regional clinical hospital in December 2018. For a long time, the patient had been treated of the small vessels disease, though main complaints were difficulties with speaking, swallowing, periodic double vision, ptosis, general weakness, weakness in the right leg, memory impairment, problems with walking and urination. The diagnosis of myasthenia was based on clinical manifestations, a positive reaction to acetylcholinesterase inhibitors, and detection of antibodies to acetylcholine receptors. Clinical manifestations of myasthenia, as well as apraxia of walking, disorders of urination and cognitive impairment due to vascular changes in the brain intensified the patient's disability and created the need for careful outside care and control of the drug intake. The positive influence of anticholinesterase drugs and prednisolone in the treatment of myasthenia was noted. The presence of diabetes mellitus is a relative contraindication to the administration of corticosteroids, but in the presence of comorbidity of generalized myasthenia and diabetes mellitus type II, prednisolone was used under constant monitoring of blood glucose by hypoglycemic agents. Thus, late-onset, severe comorbid diseases (small vessel disease of the brain, diabetes mellitus) complicate and delay the diagnosis of myasthenia and prescription of appropriate therapy.

Downloads

Download data is not yet available.

References

Carr A.S., Cardwell C.R., McCarron P.O., McConville J. A systematic review of population based epidemiological studies in Myasthenia Gravis. BMC Neurology. 2010 Jun 18;10:46. https://doi.org/10.1186/1471-2377-10-46

Alexeeva T.M., Kruchkova V.V., Stuchevskaya T.R., Halmursina A.N. Epidemiologicheskie issledovania miastenii: obsor literatury. [Epidemiological studies of myasthenia: a review of literature]. Nervno-myshechnue bolesni. 2018;8(3):12-18. Russia. https://doi.org/10.17650/2222-8721-2018-8-3-12-18

Dalakas M.C. Treating myasthenia on consensus guide: Helpful and challenging but still unfinished business. Neurology. 2016 Jul 26;87(4):350-1. https://doi.org/10.1212/WNL.0000000000002796

Dey A.K., Stamenova V., Bacopulos A., Jeyakumar N., Turner G.R., Black S.E., et al. Cognitive heterogeneity among community-dwelling older adults with cerebral small vessel disease. Neurobiol Aging. 2019 May;77:183-193. https://doi.org/10.1016/j.neurobiolaging.2018.12.011.

Evoli A., Meacci E. An update on thymectomy in myasthenia gravis. Expert Rev Neurother. 2019 Apr;5:1-11. https://doi.org/10.1080/14737175.2019.1600404.

Gilhus N.E., Tzartos S., Evoli A., Palace J., Burns T.M., Verschuuren JJG.M. Myasthenia gravis. Nat Rev Dis Primers. 2019 May 2;5(1):30. https://doi.org/10.1038/s41572-019-0079-y.

Grob D., Brunner N., Namba T., Pagala M. Lifetime course of myasthenia gravis. Muscle Nerve. 2008;37(2):141-149. https://doi.org/10.1002/mus.20950

Jordan A., Freimer M. Recent advances in understanding and managing myasthenia gravis. F1000Res. 2018 Oct 31;7. https://doi.org/10.12688/f1000research.15973.

Kalaria R.N., Hase Y.Neurovascular Ageing and Age-Related Diseases. Subcell Biochem. 2019;91:477-499. https://doi.org/10.1007/978-981-13-3681-2_17.

Kanazawa M., Shimohata T., Tanaka K., Nishizawa M. Clinical features of patients with myasthenia gravis associated with autoimmune diseases. European J Neurology. 2007;14(12):1403-1404. https://doi.org/10.1111/j.1468-1331.2007.01978.x

Keesey J.C. Clinical evaluation and management of myasthenia gravis. Muscle Nerve. 2004;29:484-505. https://doi.org/10.1002/mus.20030

Lapshyna O.V., Sedysheva D.V., Belakov K.M., Antypenko E.A, Gusev A.V. Osobennosti techenia miastenicheskogo kryza pry poznem ddebute zabolevania. [Features of the miastenin crisis current in the late disability debt]. Sovremennye problem nauki I obrazovania. 2017;4. Russia. URL: http://www.science-education.ru/ru/article/view?id=26552

McConville J., Farrugia M.E., Beeson D., Kishore U., Metcalfe R., Newsom-Davis J., et al. Detection and characterization of MuSK antibodies in seronegative myasthenia gravis. Ann. Neurol. 2004 Apr;55(4):580-4. https://doi.org/10.1002/ana.20061

Meriggioli M.N., Sanders D.B. Myasthenia gravis: diagnosis. Semin. Neurol. 2004 Mar;24(1):31-9. https://doi.org/10.1055/s-2004-829594

Mishchenko V.N., Sokolyk V.V. Bolezn melkih sosudov mozga (neuroradiologicheskie I biohemicheskie marker). [Brain small vessels disease (neuroimaging and biochemical markers)]. Ykrainskuy visnyk psyhonevrologii. 2014;4(81):41-45. Ukraine.

Orgeshkovskyu V.V. Suchasni pidhody do diagnostyky ta likuvannia miastenii gravis. [Modern approaches to the diagnosis and treatment of myasthenia gravis]. Liku Ukrainu. 2011;9(155):80–83. Ukraine.

Orgeshkovskyu V.V. Liko-indukovani porushenna nervovo-miazovoi peredachi. [physically-induced disorders of neuromuscular transmission]. Liky Ukrainu. 2010;4: 30-32. Ukraine.

Pantoni L. Cerebral small vessel disease: from pathogenesis and clini cal characteristics to therapeutic challenges. Lancet Neurol. 2010;9:689-701. https://doi.org/10.1016/S1474-4422(10)70104-6

Ponomariova E.N. Miastenia: Klinika, patogenez, dyfferencialnaya diagnostika, taktika vedenia. [Clinic, pathogenesis, differential diagnostics, tactics of conducting]. Minsk: OOO «MET»; 2002. 175 р. Russia.

Sanders D.B, Wolfe G.I., Benatar M., Evoli A., Gilhus N.E., Illa I., et al. International consensus guidance for management of myasthenia gravis. Neurology. 2016 Jul 26;87(4):419-25. https://doi.org/10.1212/WNL.0000000000002790.

Sanders D.B., Wolfe G.I., Narayanaswami P. Developing treatment guidelines for myasthenia gravis. Ann NY Acad Sci. 2018;1412(1):95-101. https://doi.org/10.1111/nyas.13537

Sardu C., Cocco E., Mereu A., Massa R., Cuccu A., Marrosu M.G., et al. Population Based Study of 12 Autoimmune Diseases in Sardinia, Italy: Prevalence and Comorbidity. PLoS One Journal. 2012;7(3):e32487. https://doi.org/10.1371/journal.pone.0032487.

Vanderpluym J., Vajsar J., Jacob F.D., Mah J.K., Grenier D., Kolski H. Clinical Characteristics of Pediatric Myasthenia: A Surveillance Study. Pediatrics. 2013;132(4):939-944. https://doi.org/10.1542/peds.2013-0814


Abstract views: 405
PDF Downloads: 162 PDF Downloads: 0
Published
2019-06-24
How to Cite
1.
Nehrych T, Bozhenko N, Kirilyuk S. MYASTHENIA – DIFFICULTIES IN DIAGNOSTICS AND TREATMENT (CLINICAL CASE ANALYSIS). Proc Shevchenko Sci Soc Med Sci [Internet]. 2019Jun.24 [cited 2022Jan.17];55(1):84-7. Available from: https://mspsss.org.ua/index.php/journal/article/view/8