Letter to the Editor
Vocal cord paralysis as a manifestation of myasthenia gravis with anti-MuSK antibodies
Parálisis de cuerdas vocales como forma de presentación de miastenia gravis con anticuerpos anti-MuSK
P.E. Jiménez Caballero
, J.A. Fermin Marrero, I. Trigo Bragado, I. Casado Naranjo
Corresponding author
Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, Spain
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Jiménez Caballero, J.A. Fermin Marrero, I. Trigo Bragado, I. Casado Naranjo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P.E." "apellidos" => "Jiménez Caballero" "email" => array:1 [ 0 => "pjimenez1010j@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.A." "apellidos" => "Fermin Marrero" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Trigo Bragado" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Casado Naranjo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Parálisis de cuerdas vocales como forma de presentación de miastenia gravis con anticuerpos anti-MuSK" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with myasthenia gravis with antibodies to muscle-specific tyrosine kinase (anti-MuSK antibodies) represent a subgroup whose characteristics differentiate them from patients with acetylcholine receptor antibodies. This disorder is predominant in women, and age of onset is typically around 40 years. Patients develop predominantly facial and bulbar symptoms and experience frequent episodes of respiratory failure. They also exhibit poor tolerance for or lack of response to cholinesterase inhibitors.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Many patients experience rapid decline at onset and plasmapheresis is the treatment of choice in some hospitals. However, long-term prognosis resembles that of patients presenting myasthenia gravis with acetylcholine receptor antibodies.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 46-year-old woman with no relevant medical history. She was admitted to the emergency department due to a 3-week history of dyspnoea with moderate exertion, predominantly in the morning, associated with dysphonia and stridor. She presented no other bulbar or ocular symptoms and no limb weakness.</p><p id="par0015" class="elsevierStylePara elsevierViewall">General examination yielded normal results. Neurological examination revealed dysphonic voice associated with stridor, which worsened with repeated efforts. It also revealed predominantly right-sided eyelid ptosis which also intensified with repetition. No ophthalmoparesis or any other pathological signs were observed during the examination. Direct laryngoscopy revealed vocal fold abduction paresis that had reduced the abduction angle by 20°. A Tensilon<span class="elsevierStyleSup">®</span> test yielded negative results.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Results from the blood test, including acetylcholine receptor antibodies and calcium channel antibodies, were negative. The patient tested positive for anti-MuSK antibodies: 9.0<span class="elsevierStyleHsp" style=""></span>nmol/L (normal <0.05). Chest radiography and CT were normal. Electromyography (EMG) showed increased jitter in the frontalis muscle and low-frequency repetitive nerve stimulation of the orbicularis oculi showed a significant decrementing response.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Treatment with pyridostigmine at doses up to 180<span class="elsevierStyleHsp" style=""></span>mg/day did not improve symptoms and was poorly tolerated, causing diarrhoea and nausea. We prescribed prednisone at a dose of 1<span class="elsevierStyleHsp" style=""></span>mg/kg/day, which lessened symptoms until the patient was asymptomatic. The dose was reduced to 20<span class="elsevierStyleHsp" style=""></span>mg/day during follow-up, as greater decreases can lead to stridor, eyelid ptosis, and diplopia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Vocal cord paralysis can be due to multiple disorders, some of which are neurological. Paralysis causes an increased resistance to airflow, and therefore dysphonia and stridor, as a consequence of weakness of the posterior cricoarytenoid muscles. Although this is rare, vocal cord paralysis may indicate onset of myasthenia gravis. Despite the low frequency of anti-MuSK antibody myasthenia gravis, several cases with a similar effect have been reported<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> because this type of myasthenia gravis mainly affects bulbar muscles. In the cases described to date, including ours, paralysis affects abduction and not adduction, and therefore the condition would preferentially affect posterior cricoarytenoid muscles.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Presence of dysphonia and stridor that intensify with fatigue should lead us to suspect bulbar myasthenia gravis. Lack of response to cholinesterase inhibitors and negative results from a test for acetylcholine receptor antibodies would not rule out this possibility. We have seen that these results are negative in cases of myasthenia gravis with anti-MuSK antibodies. Neurophysiological studies yield data typical of neuromuscular junction disease, including a decrementing response to low-frequency repetitive nerve stimulation and pathological jitter. Another entity which may cause bulbar symptoms with fatigue is Eaton-Lambert syndrome, but autonomic symptoms in these patients are usually pronounced (arterial hypertension, dry mouth, sexual dysfunction, etc.). Furthermore, during neurophysiological examination, high-frequency repetitive nerve stimulation shows facilitation, although the phenomenon in Eaton-Lambert syndrome can be indistinguishable from that of myasthenia gravis.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In myasthenia gravis with anti-MuSK antibodies, atrophy of facial and tongue muscles has been described in magnetic resonance studies.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However, this finding is normally reported when the disease is at an advanced stage and its diagnostic utility remains uncertain.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Early diagnosis of myasthenia gravis with anti-MuSK antibodies eliminates unnecessary tests and prevents delays in treatment of what may be a life-threatening condition; a patient can die of respiratory failure if the vocal cords remain closed.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-06-10" "fechaAceptado" => "2012-08-02" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jiménez Caballero PE, Fermin Marrero JA, Trigo Bragado I, Casado Naranjo I. Parálisis de cuerdas vocales como forma de presentación de miastenia gravis con anticuerpos anti-MuSK. Neurología. 2014;29:253–254.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Muscle-specific receptor tyrosine kinase antibody positive myastenia gravis current status" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S.J. Oh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3988/jcn.2009.5.2.53" "Revista" => array:7 [ "tituloSerie" => "J Clin Neurol" "fecha" => "2009" "volumen" => "5" "paginaInicial" => "53" "paginaFinal" => "64" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19587811" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028207013817" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anti-MuSK antibody myasthenia gravis. Clinical findings and response to treatment in two large cohort" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.T. Guptill" 1 => "D.B. Sanders" 2 => "A. Evoli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/mus.22006" "Revista" => array:6 [ "tituloSerie" => "Muscle Nerve" "fecha" => "2011" "volumen" => "44" "paginaInicial" => "36" "paginaFinal" => "40" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21674519" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dyspnoea due to vocal fold abduction paresis in anti-MuSK myasthenia gravis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Sylva" 1 => "A.J. van der Kooi" 2 => "W. Grolman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/jnnp.2007.135319" "Revista" => array:6 [ "tituloSerie" => "J Neurol Neurosurg Psychiatry" "fecha" => "2008" "volumen" => "79" "paginaInicial" => "1083" "paginaFinal" => "1084" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18708570" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vocal cord paralysis in myasthenia gravis with anti-MuSK antibodies" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. Hara" 1 => "T. Mashima" 2 => "A. Matsuda" 3 => "K. Tanaka" 4 => "M. Tomita" 5 => "H. Shiraishi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1212/01.wnl.0000254617.15644.f4" "Revista" => array:6 [ "tituloSerie" => "Neurology" "fecha" => "2007" "volumen" => "68" "paginaInicial" => "621" "paginaFinal" => "622" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17310039" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "MRI and clinical studies of facial and bulbar muscle involvement in MuSK antibody-associated myasthenia gravis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.E. Farrugia" 1 => "M.D. Robson" 2 => "L. Clover" 3 => "P. Anslow" 4 => "J. Newsom-Davis" 5 => "R. Kennett" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/brain/awl095" "Revista" => array:6 [ "tituloSerie" => "Brain" "fecha" => "2006" "volumen" => "129" "paginaInicial" => "1481" "paginaFinal" => "1492" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16672291" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735808/0000002900000004/v1_201405040018/S2173580814000352/v1_201405040018/en/main.assets" "Apartado" => array:4 [ "identificador" => "17109" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "CO1" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735808/0000002900000004/v1_201405040018/S2173580814000352/v1_201405040018/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580814000352?idApp=UINPBA00004N" ]
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| 2021 April | 123 | 12 | 135 |
| 2021 March | 61 | 19 | 80 |
| 2021 February | 71 | 11 | 82 |
| 2021 January | 71 | 17 | 88 |
| 2020 December | 68 | 13 | 81 |
| 2020 November | 58 | 21 | 79 |
| 2020 October | 52 | 6 | 58 |
| 2020 September | 53 | 12 | 65 |
| 2020 August | 52 | 10 | 62 |
| 2020 July | 43 | 10 | 53 |
| 2020 June | 35 | 8 | 43 |
| 2020 May | 41 | 17 | 58 |
| 2020 April | 45 | 3 | 48 |
| 2020 March | 52 | 14 | 66 |
| 2020 February | 71 | 14 | 85 |
| 2020 January | 72 | 8 | 80 |
| 2019 December | 60 | 9 | 69 |
| 2019 November | 59 | 8 | 67 |
| 2019 October | 72 | 18 | 90 |
| 2019 September | 98 | 7 | 105 |
| 2019 August | 78 | 8 | 86 |
| 2019 July | 58 | 23 | 81 |
| 2019 June | 106 | 38 | 144 |
| 2019 May | 224 | 37 | 261 |
| 2019 April | 139 | 53 | 192 |
| 2019 March | 43 | 22 | 65 |
| 2019 February | 42 | 16 | 58 |
| 2019 January | 29 | 20 | 49 |
| 2018 December | 48 | 14 | 62 |
| 2018 November | 27 | 11 | 38 |
| 2018 October | 38 | 12 | 50 |
| 2018 September | 7 | 5 | 12 |
| 2018 August | 5 | 30 | 35 |
| 2018 July | 17 | 27 | 44 |
| 2018 June | 16 | 26 | 42 |
| 2018 May | 14 | 13 | 27 |
| 2018 April | 10 | 16 | 26 |
| 2018 March | 11 | 16 | 27 |
| 2018 February | 16 | 7 | 23 |
| 2018 January | 18 | 10 | 28 |
| 2017 December | 26 | 12 | 38 |
| 2017 November | 21 | 11 | 32 |
| 2017 October | 18 | 15 | 33 |
| 2017 September | 15 | 17 | 32 |
| 2017 August | 17 | 12 | 29 |
| 2017 July | 14 | 19 | 33 |
| 2017 June | 9 | 21 | 30 |
| 2017 May | 14 | 19 | 33 |
| 2017 April | 16 | 19 | 35 |
| 2017 March | 10 | 31 | 41 |
| 2017 February | 16 | 21 | 37 |
| 2017 January | 28 | 15 | 43 |
| 2016 December | 15 | 21 | 36 |
| 2016 November | 25 | 25 | 50 |
| 2016 October | 21 | 19 | 40 |
| 2016 September | 16 | 21 | 37 |
| 2016 August | 13 | 15 | 28 |
| 2016 July | 13 | 4 | 17 |
| 2016 June | 21 | 24 | 45 |
| 2016 May | 15 | 25 | 40 |
| 2016 April | 12 | 21 | 33 |
| 2016 March | 34 | 31 | 65 |
| 2016 February | 21 | 21 | 42 |
| 2016 January | 14 | 17 | 31 |
| 2015 December | 16 | 15 | 31 |
| 2015 November | 35 | 23 | 58 |
| 2015 October | 23 | 22 | 45 |
| 2015 September | 21 | 12 | 33 |
| 2015 August | 35 | 7 | 42 |
| 2015 July | 25 | 7 | 32 |
| 2015 June | 20 | 4 | 24 |
| 2015 May | 37 | 7 | 44 |
| 2015 April | 29 | 14 | 43 |
| 2015 March | 32 | 13 | 45 |
| 2015 February | 24 | 4 | 28 |
| 2015 January | 31 | 9 | 40 |
| 2014 December | 37 | 9 | 46 |
| 2014 November | 21 | 6 | 27 |
| 2014 October | 33 | 8 | 41 |
| 2014 September | 35 | 4 | 39 |
| 2014 August | 40 | 11 | 51 |
| 2014 July | 43 | 12 | 55 |
| 2014 June | 35 | 10 | 45 |
| 2014 May | 51 | 22 | 73 |
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