Clinical and Electrophysiologic Responses to Acetylcholinesterase Inhibitors in MuSK-Antibody-Positive Myasthenia Gravis: Evidence for Cholinergic Neuromuscular Hyperactivity
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Background and Purpose Patients with muscle-specific tyrosine kinase (MuSK) antibody(MuSK-Ab)-positive myasthenia gravis (MG) show distinct responses to acetylcholinesteraseinhibitors (AChEIs). Although clinical responses to AChEIs in MuSK-Ab MG are reasonablywell known, little is known about the electrophysiologic responses to AChEIs. We therefore investigated the clinical and electrophysiologic responses to AChEIs in MuSK-Ab-positive MGpatients. Methods We retrospectively reviewed the medical records and electrodiagnostic findings of17 MG patients (10 MuSK-Ab-positive and 7 MuSK-Ab-negative patients) who underwentelectrodiagnostic testing before and after a neostigmine test (NT). Results The frequency of intolerance to pyridostigmine bromide (PB) was higher in MuSKAb-positive patients than in MuSK-Ab-negative patients (50% vs. 0%, respectively; p=0.044),while the maximum tolerable dose of PB was lower in the former (90 mg/day vs. 480 mg/day,p=0.023). The frequency of positive NT results was significantly lower in MuSK-Ab-positivepatients than in MuSK-Ab-negative patients (40% vs. 100%, p=0.035), while the nicotinic sideeffects of neostigmine were more frequent in the former (80% vs. 14.3%, p=0.015). Repetitivecompound muscle action potentials (R-CMAPs) developed more frequently after NT in MuSKAb-positive patients than in MuSK-Ab-negative patients (90% vs. 14.3%, p=0.004). The frequency of a high-frequency-stimulation-induced decrement-increment pattern (DIP) was higherin MuSK-Ab-positive patients than in MuSK-Ab-negative patients (100% vs. 17.7%, p=0.003). Conclusions These results suggest that MuSK-Ab-positive MG patients exhibit unique andhyperactive responses to AChEIs. Furthermore, R-CMAP and DIP development on a standardAChEI dose may be a distinct neurophysiologic feature indicative of MuSK-Ab-positive MG.
Abstract
Background and Purpose Patients with muscle-specific tyrosine kinase (MuSK) antibody(MuSK-Ab)-positive myasthenia gravis (MG) show distinct responses to acetylcholinesteraseinhibitors (AChEIs). Although clinical responses to AChEIs in MuSK-Ab MG are reasonablywell known, little is known about the electrophysiologic responses to AChEIs. We therefore investigated the clinical and electrophysiologic responses to AChEIs in MuSK-Ab-positive MGpatients. Methods We retrospectively reviewed the medical records and electrodiagnostic findings of17 MG patients (10 MuSK-Ab-positive and 7 MuSK-Ab-negative patients) who underwentelectrodiagnostic testing before and after a neostigmine test (NT). Results The frequency of intolerance to pyridostigmine bromide (PB) was higher in MuSKAb-positive patients than in MuSK-Ab-negative patients (50% vs. 0%, respectively; p=0.044),while the maximum tolerable dose of PB was lower in the former (90 mg/day vs. 480 mg/day,p=0.023). The frequency of positive NT results was significantly lower in MuSK-Ab-positivepatients than in MuSK-Ab-negative patients (40% vs. 100%, p=0.035), while the nicotinic sideeffects of neostigmine were more frequent in the former (80% vs. 14.3%, p=0.015). Repetitivecompound muscle action potentials (R-CMAPs) developed more frequently after NT in MuSKAb-positive patients than in MuSK-Ab-negative patients (90% vs. 14.3%, p=0.004). The frequency of a high-frequency-stimulation-induced decrement-increment pattern (DIP) was higherin MuSK-Ab-positive patients than in MuSK-Ab-negative patients (100% vs. 17.7%, p=0.003). Conclusions These results suggest that MuSK-Ab-positive MG patients exhibit unique andhyperactive responses to AChEIs. Furthermore, R-CMAP and DIP development on a standardAChEI dose may be a distinct neurophysiologic feature indicative of MuSK-Ab-positive MG.
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