Comorbid Human Immunodeficiency Virus (HIV) and Muscle-Specific Kinase (MuSK) Myasthenia Gravis: A Case Report and Literature Review

Sherpa, Michael; Metai, Ravi K.; Kumar, Viki; Hirachan, Tinu; Ahmed, Kawser; Atkinson, Sharon

doi:10.12659/ajcr.903108

Cited by 10 publications

(8 citation statements)

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“…Management is the same as for AIDP/CIDP/non-HIV including immunomodulation in AIDP and steroids in CIDP. The response to immunomodulation treatment and outcome are reported to be largely similar in both HIV and non-HIV groups149,180 a higher mortality rate was reported in AIDP/HIV in one study in Tanzania178.…”

Section: Resultsmentioning

confidence: 91%

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Neurological disorders in HIV in Africa: a review

Howlett¹

2019

Afr H. Sci.

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BackgroundNeurological disorders in HIV infection are a common cause of morbidity and mortality. The aim of this paper is to provide a narrative overview of up to date information concerning neurological disorders affecting HIV infected persons in Africa.MethodsSeminal research concerning neurological disorders among HIV-infected adults in sub-Saharan Africa from prior to 2000 was combined with an in-depth search of PubMed to identify literature published from 2000 to 2017. The following Mesh terms were used. “Nervous System Diseases” “HIV Infections” and “Africa South of the Sahara” and “Seizures” or “Spinal Cord Diseases” or “Peripheral Nervous System Diseases” or “AIDS Dementia Complex” or “Opportunistic Infections” or “Immune Reconstitution Inflammatory Syndrome” or “Stroke”. Only those articles written in English were used. A total of 352 articles were identified, selected and reviewed and 180 were included in the study. These included case series, observational studies, interventional studies, guidelines and reviews with metanalyses. The author also included 15 publications on the subject covering the earlier phase of the HIV epidemic in Africa from 1987 to 1999 making a total of 195 references in the study. This was combined with extensive personal experience diagnosing and treating these neurological disorders.ResultsNeurological disorders were common, typically occurring in WHO stages III/IV. These were in three main categories: those arising from opportunistic processes mostly infections, direct HIV infection and autoimmunity. The most common were those arising from direct HIV infection occurring in >50%. These included HIV-associated neurocognitive dysfunction (HAND), neuropathy and myelopathy. Opportunistic infections occurred in >20% and frequently had a 6–9-month mortality rate of 60–70%. The main causes were cryptococcus, tuberculosis, toxoplasmosis and acute bacterial meningitis. Concurrent systemic tuberculosis occurred in almost 50%.ConclusionNeurological disorders are common in HIV in Africa and the main CNS opportunistic infections result in high mortality rates. Strategies aimed at reducing their high burden, morbidity and mortality include early HIV diagnosis and anti-retroviral therapy (ART), screening and chemoprophylaxis of main opportunistic infections, improved clinical diagnosis and management and programme strengthening.

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Section: Resultsmentioning

confidence: 91%

“…Myasthenia gravis is associated with HIV and while the overall incidence rate of MG in SA177 is similar to that reported in HICs there are no published reports of MG/HIV from Africa. MG/HIV typically occurs as part of post ART immune restoration or IRIS and responds to standard MG treatment178.…”

Section: Resultsmentioning

confidence: 99%

Neurological disorders in HIV in Africa: a review

Howlett¹

2019

Afr H. Sci.

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“…However, multiphasic, or recurrent ADEM, as well as atypical neuroimaging manifestations have been documented in PLHIV (87,88). Other autoimmune neurological diseases have been documented in PLHIV including myasthenia gravis, N-methyl-D-aspartate-receptor antibody encephalitis, HIV-associated opsoclonus-myoclonus-ataxia syndrome, and neuromyelitis optica with or without detectable anti-aquaporin-4 autoantibodies (89)(90)(91)(92). Inflammatory neurological diseases caused by unknown mechanisms have also been documented in PLHIV.…”

Section: Autoimmune Neurological Diseasesmentioning

confidence: 99%

Post-Infectious Autoimmunity in the Central (CNS) and Peripheral (PNS) Nervous Systems: An African Perspective

et al. 2022

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The direct impact and sequelae of infections in children and adults result in significant morbidity and mortality especially when they involve the central (CNS) or peripheral nervous system (PNS). The historical understanding of the pathophysiology has been mostly focused on the direct impact of the various pathogens through neural tissue invasion. However, with the better understanding of neuroimmunology, there is a rapidly growing realization of the contribution of the innate and adaptive host immune responses in the pathogenesis of many CNS and PNS diseases.The balance between the protective and pathologic sequelae of immunity is fragile and can easily be tipped towards harm for the host. The matter of immune privilege and surveillance of the CNS/PNS compartments and the role of the blood-brain barrier (BBB) and blood nerve barrier (BNB) makes this even more complex. Our understanding of the pathogenesis of many post-infectious manifestations of various microbial agents remains elusive, especially in the diverse African setting. Our exploration and better understanding of the neuroimmunology of some of the infectious diseases that we encounter in the continent will go a long way into helping us to improve their management and therefore lessen the burden.Africa is diverse and uniquely poised because of the mix of the classic, well described, autoimmune disease entities and the specifically “tropical” conditions. This review explores the current understanding of some of the para- and post-infectious autoimmune manifestations of CNS and PNS diseases in the African context. We highlight the clinical presentations, diagnosis and treatment of these neurological disorders and underscore the knowledge gaps and perspectives for future research using disease models of conditions that we see in the continent, some of which are not uniquely African and, where relevant, include discussion of the proposed mechanisms underlying pathogen-induced autoimmunity. This review covers the following conditions as models and highlight those in which a relationship with COVID-19 infection has been reported: a) Acute Necrotizing Encephalopathy; b) Measles-associated encephalopathies; c) Human Immunodeficiency Virus (HIV) neuroimmune disorders, and particularly the difficulties associated with classical post-infectious autoimmune disorders such as the Guillain-Barré syndrome in the context of HIV and other infections. Finally, we describe NMDA-R encephalitis, which can be post-HSV encephalitis, summarise other antibody-mediated CNS diseases and describe myasthenia gravis as the classic antibody-mediated disease but with special features in Africa.

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“…Wirtz et al also described a patient who developed MG during ART with positive MuSK antibody [18]. In contrast to the lower incidence of reported MuSK antibody in HIV-negative patients, the MuSK antibody was more frequently detected in HIV-infected patients at the time of IRIS [4,6,13,14,19]. Sherpa et al proposed that patients with MuSK-related MG have a much lower frequency of thymic pathology than patients with AChR-Ab(+) MG due to no thymus enlargement in reported patients with MuSK MG [14].…”

Section: Discussionmentioning

confidence: 99%

Comorbidity of Myasthenia gravis and Graves' disease as immune reconstitution‐associated autoimmune disease in HIV infection: A case report and literature review

Lu,

Ma,

Cong

et al. 2023

HIV Medicine

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BackgroundComorbidity of Myasthenia gravis (MG) and Graves' disease (GD) in treated HIV‐infected individuals has rarely been described and little study has been done on the link between HIV‐related immune reconstitution and autoimmune diseases occurring post antiretroviral therapy.Case PresentationHere we report on a 33‐year‐old Chinese man with HIV infection who had been virologically suppressed since 2018. The patient was diagnosed with GD and was treated in 2020. Early in 2022, he developed fluctuating weakness and fatigue involving the bilateral extraocular muscles and limbs. With a positive neostigmine test, he was considered to have MG, but showed a poor response to oral medication. After multiple failed medication attempts, a thymectomy was finally performed to resolve his symptoms. The consecutive onset of immunological events may have partially resulted from immune reconstitution after viral control.ConclusionsThis is a rare case of HIV‐related immune reconstitution‐associated autoimmune disease (IRAD) with comorbidity of MG and GD which was reported initially. Cooperation with multidisciplinary teams is essential to avoid misdiagnosis and to promote the overall health of HIV‐infected patients.

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Comorbid Human Immunodeficiency Virus (HIV) and Muscle-Specific Kinase (MuSK) Myasthenia Gravis: A Case Report and Literature Review

Cited by 10 publications

References 10 publications

Neurological disorders in HIV in Africa: a review

Neurological disorders in HIV in Africa: a review

Post-Infectious Autoimmunity in the Central (CNS) and Peripheral (PNS) Nervous Systems: An African Perspective

Comorbidity of Myasthenia gravis and Graves' disease as immune reconstitution‐associated autoimmune disease in HIV infection: A case report and literature review

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