Myasthenia gravis exacerbation after melatonin administration: case series from a tertiary referral centre
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CASE REPORT
Open Access
Myasthenia gravis exacerbation after melatonin administration: case series from a tertiary referral centre Velina Nedkova-Hristova1,2,3, Valentina Vélez-Santamaría1,2,3,4 and Carlos Casasnovas1,2,3,4,5*
Abstract Background: Myasthenia gravis is an autoimmune disease mediated by antibodies against proteins associated with the postsynaptic membrane of the neuromuscular junction. Several drugs may trigger an exacerbation of the disease. Melatonin supplements are widely used for the treatment of insomnia as they are well tolerated with few side effects. The role of melatonin in the immune system and its effects in autoimmune disorders remain uncertain. Case presentation: We identified three patients in our referral centre from 2014 to 2019 who presented a worsening within days or weeks of starting melatonin. Two of them stopped the treatment without clinical improvement in the next week. Increasing dose of corticosteroids did not lead to clinical improvement in the next month and one of the patients was finally administered intravenous immunoglobulins. Conclusion: Melatonin may trigger exacerbations of myasthenia gravis, probably due to an upregulation of the adaptive immune system and an interaction with the corticosteroids and other immunosuppressant treatments. We consider that melatonin should be administered with caution in these patients. Keywords: Melatonin, Myasthenia gravis, Corticosteroid, Immunosuppressant, Case report
Background Myasthenia gravis (MG) is an autoimmune disease mediated by antibodies against the acetylcholine receptor (antiAchR), the muscle-specific kinase (anti-MuSK) or other proteins associated with the postsynaptic membrane of the neuromuscular junction. The main clinical manifestations are muscle weakness and fatigue (which worsens after repeated muscular effort) [1]. Symptoms may be exclusively ocular (ocular MG), with diplopia and/or ptosis, or generalized (generalized MG), involving weakness of the limb, trunk, dysphagia, dysphonia or respiratory insufficiency. * Correspondence: [email protected] 1 Neuromuscular Diseases Unit, Department of Neurology, Bellvitge University Hospital -IDIBELL, Carrer de la Feixa Llarga, s/n, 08907, L’Hospitalet de Llobregat, Barcelona, Spain 2 Bellvitge Institute for Biomedical Research (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain Full list of author information is available at the end of the article
Several drugs, notably sedatives and some antibiotics may trigger an exacerbation of MG and hence they should be used with caution, weighing up the risks and benefits in each patient. Some over-the-counter pharmacy products may also contain substances that worsen the symptoms of MG. Melatonin (N-acetyl-5-methoxytryptamine) is a hormone that is primarily released by the pineal gland and which is involved in regulating the sleep-wake cycle. Levels of melatonin decrease with age and this could be one of the reasons why older adults are more prone to suffer from insomnia [2]. Because exogenous melatonin
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