Adalimumab-induced myasthenia gravis: case-based review
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Rheumatology INTERNATIONAL
CASE BASED REVIEW
Adalimumab‑induced myasthenia gravis: case‑based review Eleftherios Pelechas1 · Tereza Memi1 · Theodora E. Markatseli1 · Paraskevi V. Voulgari1 · Alexandros A. Drosos1 Received: 22 January 2020 / Accepted: 11 April 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Myasthenia gravis (MG) is an autoimmune disease characterised by the presence of acetylcholine receptor antibodies and by blocking the transmission of the signal in the neuromuscular junction causing muscle weakness. It can be associated with several autoimmune diseases and certain drugs, between them Etanercept an anti-tumour necrosis factor (TNF) agent. A 42-year-old woman with rheumatoid arthritis (RA) refractory to methotrexate, was treated with adalimumab (ADA), a human monoclonal antibody against the TNF, in a dosage scheme of 40 mg every 14 days subcutaneously. The patient responded well to ADA therapy with sustained remission for 18 months when she developed blurred vision and eyelid ptosis of the left eye. The diagnosis of ocular MG was made. ADA has been discontinued and she started a treatment with pyridostigmine showing an excellent response and complete remission within a 2-month period. This is the first report making an association of ADA and ocular MG. Thus, rheumatologists dealing with patients treated with TNF inhibitors should be aware of the possible development of neurological adverse events, among them MG. Keywords Myasthenia gravis · Anti-TNFα · Etanercept · Adalimumab · Neuromuscular junction · Muscle weakness
Introduction Nowadays, the biological (b) disease-modifying anti-rheumatic drugs (DMARDs), especially those targeting TNF (tumor necrosis factor) α have revolutionized the treatment of inflammatory arthritides (IA) including rheumatoid arthritis (RA). On the other hand, TNFα is also a component of the immune system, which is involved in a variety of physiological immune responses [1]. Therefore, by blocking TNFα, many adverse events may occur, such as viral * Alexandros A. Drosos [email protected] Eleftherios Pelechas [email protected] Tereza Memi [email protected] Theodora E. Markatseli [email protected] Paraskevi V. Voulgari [email protected] 1
Department of Internal Medicine, Medical School, Rheumatology Clinic, University of Ioannina, 45110 Ioannina, Greece
or bacterial infections, opportunistic infections and autoimmune phenomena [2]. Many autoimmune diseases and phenomena have been reported ranging from the isolated presence of an autoantibody to full-blown autoimmune diseases, organ specific or even systemic diseases. Myasthenia gravis (MG) is an autoimmune disease characterised by the presence of antibodies against nicotinic acetylcholine receptors (AchRs), which block the transmission of nerve-to-muscle signals (neuromuscular junction). As a result, muscle weakness occurs. It affects individuals between 30 and 45 years and especially women. As a clinical entity, it can occur alone or in association with thymic hyperplas
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