Extracorporeal Immunoglobulin Elimination for the Treatment of Severe Myasthenia Gravis

Myasthenia gravis (MG) is a neuromuscular disorder leading to fluctuating muscle weakness and fatigue. Rarely, long-term stabilization is not possible through the use of thymectomy or any known drug therapy. We present our experience with extracorporeal immunoglobulin (Ig) elimination by immunoadsorption (adsorbers with human Ig antibodies). Acetylcholine receptor antibodies (AChRAs) were measured during long-term monitoring (4.7 ± 2.9 years; range 1.1–8.0). A total of 474 samples (232 pairs) were analyzed, and a drop in AChRA levels was observed (P = .025). The clinical status of patients improved and stabilized. Roughly 6.8% of patients experienced clinically irrelevant side effects. The method of Ig elimination by extracorporeal immunoadsorption (IA) is a clinical application of the recent biotechnological advances. It offers an effective and safe therapy for severe MG even when the disease is resistant to standard therapy

Pigmentary retinopathy can indicate the presence of pathogenic LAMP2 variants even in somatic mosaic carriers with no additional signs of Danon disease

PURPOSE: Danon disease (DD) is a rare X-linked disorder caused by pathogenic variants in LAMP2. DD primarily manifests as a severe cardiomyopathy. An early diagnosis is crucial for patient survival. The aim of the study was to determine the usefulness of ocular examination for identification of DD. METHODS: Detailed ocular examination in 10 patients with DD (3 males, 7 females) and a 45-year-old asymptomatic female somatic mosaic carrier of a LAMP2 disease-causing variant. RESULTS: All patients with manifest cardiomyopathy had pigmentary retinopathy with altered autofluorescence and diffuse visual field loss. Best corrected visual acuity (BCVA) was decreased (<0.63) in 8 (40%) out of 20 eyes. The severity of retinal pathology increased with age, resulting in marked cone-rod involvement overtime. Spectral-domain optical coherence tomography in younger patients revealed focal loss of photoreceptors, disruption and deposition at the retinal pigment epithelium/Bruch's membrane layer (corresponding to areas of marked increased autofluorescence), and hyperreflective foci in the outer nuclear layer. Cystoid macular oedema was seen in one eye. In the asymptomatic female with somatic mosaicism, the BCVA was 1.0 bilaterally. An abnormal autofluorescence pattern in the left eye was present; while full-field electroretinography was normal. CONCLUSIONS: Detailed ocular examination may represent a sensitive and quick screening tool for the identification of carriers of LAMP2 pathogenic variants, even in somatic mosaicism. Hence, further investigation should be undertaken in all patients with pigmentary retinal dystrophy as it may be a sign of a life-threatening disease

GLOWORM-PARA: a flexible framework to simulate the population dynamics of the parasitic phase of gastrointestinal nematodes infecting grazing livestock

Gastrointestinal (GI) nematodes are a significant threat to the economic and environmental sustainability of keeping livestock, as adequate control becomes increasingly difficult due to the development of anthelmintic resistance (AR) in some systems and climate-driven changes to infection dynamics. To mitigate any negative impacts of climate on GI nematode epidemiology and slow AR development, there is a need to develop effective, targeted control strategies that minimise the unnecessary use of anthelmintic drugs and incorporate alternative strategies such as vaccination and evasive grazing. However, the impacts climate and GI nematode epidemiology may have on the optimal control strategy are generally not considered, due to lack of available evidence to drive recommendations. Parasite transmission models can support control strategy evaluation to target field trials, thus reducing the resources and lead-time required to develop evidence-based control recommendations incorporating climate stochasticity. GI nematode population dynamics arising from natural infections have been difficult to replicate and model applications have often focussed on the free-living stages. A flexible framework is presented for the parasitic phase of GI nematodes, GLOWORM-PARA, which complements an existing model of the free-living stages, GLOWORM-FL. Longitudinal parasitological data for two species that are of major economic importance in cattle, Ostertagia ostertagi and Cooperia oncophora, were obtained from seven cattle farms in Belgium for model validation. The framework replicated the observed seasonal dynamics of infection in cattle on these farms and overall, there was no evidence of systematic under- or over-prediction of faecal egg counts (FECs). However, the model under-predicted the FECs observed on one farm with very young calves, highlighting potential areas of uncertainty that may need further investigation if the model is to be applied to young livestock. The model could be used to drive further research into alternative parasite control strategies such as vaccine development and novel treatment approaches, and to understand GI nematode epidemiology under changing climate and host management

Clinical electrophysiology of two rod pathways: normative values and clinical application

Background: The scotopic 15-Hz flicker electroretinogram (ERG) has two limbs (slow and fast ERG rod signals), and these have been attributed to two retinal rod pathways (the ON rod bipolar and AII amacrine pathway and the rod-cone gap-junction pathway). The aim of this study was to provide normative values of the scotopic 15-Hz flicker ERG, to estimate the inter-individual variability, and to apply this method to a clinical setting. Methods: Twenty-two normal subjects, one patient with retinitis pigmentosa (RP), and two patients with Stargardt's macular dystrophy (SMD) participated in the study. The SMD patients were screened for mutations in the 50 exons of the ABCA4 (formerly ABCR) gene. We measured ERG response amplitudes and phases to flicker intensities ranging from –3.37 to –0.57 log scotopic trolands s at a flicker frequency of 15 Hz. Results: The normal scotopic 15-Hz flicker ERG showed a biphasic amplitude pattern with a minimum at about –1.57 log scotopic trolands s, where there was an abrupt phase shift of about 180 deg. The inter-individual variability in ERG amplitude ranged from 47% to 67% for the slow and from 41% to 64% for the fast rod signal. Both the RP patient and the SMD patients (who were compound heterozygotes for mutations in the ABCA4 gene) showed reduced amplitudes for the two rod ERG pathways. Conclusion: The inter-individual variability might be explained by anatomical differences between individual retinae. In the RP patient, the amplitude reductions corresponded well with the standard rod ERG. In the SMD patients, however, the scotopic 15-Hz flicker ERG revealed rod dysfunction, whereas the standard rod ERG was within normal limits. The scotopic 15-Hz flicker method may be more sensitive than the standard rod ERG

Acute posterior multifocal placoid pigment epitheliopathy in a child. Case report

To present our findings and the course of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) with macular edema in a child