NEUROMUSCULAR DISEASES

01955616/02 $15.00 .00

MYASTHENIA GRAVIS AND DISORDERS OF NEUROMUSCULAR TRANSMISSION

G. Diane Shelton, DVM, PhD

Myasthenia gravis (MG) is a disorder of neuromuscular transmission resulting from either a deciency or functional disorder of the nicotinic acetylcholine receptor (AChR) as in congenital MG (CMG) or an autoimmune attack against AChRs resulting in depletion of receptors in acquired MG.38 In either case, the result is focal or generalized clinical muscular weakness. CMG is a rare disorder that has been reported in only a few breeds. The autoimmune form of MG is relatively common in dogs and also occurs in cats. The nicotinic AChR plays a central role in neuromuscular transmission in skeletal muscle (Fig. 1), and any disruption of structure or function can interfere with the overall control of muscle contraction, resulting in muscle weakness. When an action potential (the signal for neuromuscular transmission) reaches the nerve terminal, a decrease in the membrane potential leads to transient opening of presynaptic Ca channels. Ca inux into the nerve terminal stimulates the release of acetylcholine (ACh), which binds to AChRs on the postsynaptic membrane. AChRs are cation channels permeable to Na and K that transiently open as a result of ACh binding. The net ux of Na results in a wave of depolarization (muscle action potential) that spreads in all
This work was partially supported by a grant from the California Myasthenia Gravis Foundation.

From the Department of Pathology, School of Medicine, University of California, San Diego, La Jolla, California

VETERINARY CLINICS OF NORTH AMERICA: SMALL ANIMAL PRACTICE

VOLUME 32 NUMBER 1 JANUARY 2002

189

190

SHELTON

Figure 1. Demonstration of the importance of the AChR in the coupling of neuronal impulses to the activation of muscle contractile elements. The numbers indicate the sequence of activation of important events: 1 opening of presynaptic Ca channels: 2 release of ACh: 3 binding of ACh to AChRs with resultant increased ux of Na and K: 4 opening of Na channels: and 5 opening of Ca channels in the transverse tubules and sarcoplasmic reticulum. This sudden increase in sarcoplasmic Ca mediates contraction of myobrils. (From Shelton GD, Cardinet III GH: Pathophysiologic basis of canine muscle disorders. J Vet Intern Med 1:3644, 1987; with permission.)

MYASTHENIA GRAVIS AND DISORDERS OF NEUROMUSCULAR TRANSMISSION

191

directions of the muscle ber sarcolemma, ultimately resulting in muscle contraction. Each signal must be rapidly terminated to ready the muscle for the next signal. Acetylcholinesterase (AChE) hydrolyzes ACh rapidly and is responsible for this termination. Factors that interfere with presynaptic Ca channel function, ACh release, binding of ACh to postsynaptic AChRs, or degradation of ACh can result in inadequate synaptic transmission and clinical weakness. CONGENITAL MYASTHENIA GRAVIS To date, CMG is rarely recognized in veterinary medicine, and only a few breed-associated disorders have been described. A congenital familial form of MG inherited as an autosomal recessive trait has been described in Jack Russell Terriers,36 Springer Spaniels,36 and Smooth Fox Terriers.40 In all three breeds, CMG was characterized as a postsynaptic defect with deciency of AChR at the neuromuscular junction, without evidence of autoimmunity. Low-density AChR caused by a low insertion of AChR in the postsynaptic membrane was the suggested defect in the Jack Russell Terrier47 and the Springer Spaniel.47 An autosomal recessive congenital myasthenic syndrome with a suspected presynaptic defect has been reported in Gammel Dansk Honsehunds, a Danish bird dog.17, 67 Electrophysiologic studies showed facilitation of the compound muscle action potential on high-frequency stimulation with improvement after test doses of guanidine. Anticholinesterase treatment had no effect on muscle weakness or electrophysiologic parameters. A poorly classied congenital myasthenic syndrome has also been identied in Miniature Dachshunds, in which anticholinesterase-responsive weakness begins at approximately 5 to 6 weeks of age and resolves with maturation, no longer requiring therapy (G.D. Shelton, DVM, PhD, unpublished data). This improvement with age has some similarities to familial infantile myasthenia as described in human beings.42, 52 A few cats have also been reported with CMG.24, 27 Several congenital myasthenic syndromes are described in human beings,15 and it is likely that similar syndromes also occur in dogs and cats. Diagnosis A genetic or congenital myasthenic syndrome should be considered in any young animal with weakness that worsens on sustained exercise. Although regurgitation associated with megaesophagus has been reported in CMG,40 it does not occur as commonly as in acquired MG, where approximately 90% of affected dogs have esophageal dilatation.60 Tendon reexes are usually preserved but may be fatigable. Serologic tests for AChR antibodies are negative. A positive intravenous edrophonium response test (0.10.2 mg/kg administered intravenously) can be consistent with the diagnosis of CMG but does not differentiate it from

192

SHELTON

acquired autoimmune MG. A negative test does not exclude the diagnosis of CMG, as human patients with neuromuscular junction (NMJ) AChE deciency or a defect in ACh resynthesis or packaging have a negative test.15 The test is also inconsistently positive in the slow-channel syndrome and in the high-conductance fast-channel syndrome.15 Routine electrophysiologic, serologic, and morphologic evaluations should exclude other neuromuscular disorders. Cytochemical and immunocytochemical evaluations should also be performed on fresh-frozen biopsy specimens for localization of AChE, AChR, AChR subunits, IgG, and complement components at the NMJ. Quantication of muscle AChR and antibody-bound AChR concentration can provide information on AChR deciency syndromes.36 Further investigations of CMG require specialized ultrastructural and in vitro electrophysiologic testing that currently can be performed at only a few specialized medical centers. Ultrastructural examination includes careful evaluation of the ne structure of the motor end plate. The in vitro electrophysiologic studies require a fresh muscle specimen intact from origin to insertion such as the external intercostal14 or anconeus muscle.39 The in vitro studies should include information on parameters of quantal release, the postsynaptic response to transmitter quanta, and the kinetic properties of the AChR channel.15

Response to Therapy The response to therapy depends on the cause of the myasthenic syndrome. In animals with an associated AChR deciency, anticholinesterase drugs should be of benet. Long-term treatment of CMG is usually unsatisfactory, however, and full return of strength is unusual. Weakness in dogs with CMG can progress to death within 1 year; however, with intensive supportive care and anticholinesterase therapy (see section on acquired MG), affected Jack Russell terriers have survived several years.27 The two reported cats with CMG also survived several years.27

ACQUIRED MYASTHENIA GRAVIS Acquired MG is the most completely characterized autoimmune disease affecting the neuromuscular system, and, arguably, the most completely characterized autoimmune disease in general.38 Unlike most other autoimmune diseases, the inciting autoantigen is known, there are specic and sensitive diagnostic tests available, and there are relatively specic therapies. As a result of autoantibody-mediated destruction of nicotinic AChRs at the NMJ, there is clinically apparent muscular weakness and excessive fatigability that may affect ocular, facial, oropharyngeal, esophageal, or limb muscles. Acquired MG is probably the most

MYASTHENIA GRAVIS AND DISORDERS OF NEUROMUSCULAR TRANSMISSION

193

common neuromuscular disease that can be diagnosed and treated in dogs.56, 58, 60 Although less common in cats,61 MG should also be considered in any cat that is presented with recent onset of muscular weakness. Clinical Presentation Because of the propensity of canine MG to mimic other myopathic and neuropathic disorders, acquired MG should be high on the list of differential diagnoses in any dog with focal or generalized neuromuscular weakness.56 Presenting clinical signs may be focal in nature and limited to regurgitation (as a result of esophageal dilatation), dysphagia (as a result of pharyngeal dysfunction), voice change (as a result of laryngeal paralysis), or multiple cranial nerve abnormalities in the absence of generalized muscle weakness. In a recent study,60 43% of the dogs with a conrmed diagnosis of MG by the demonstration of a positive AChR antibody titer did not have clinically detectable limb muscle weakness. Generalized weakness was present in the remaining 57%, with 13% of these dogs having generalized weakness in the absence of esophageal or pharyngeal dysfunction. A severe form of MG, acute fulminating MG, has been described.10, 30 These cases were associated with sudden onset of esophageal dilatation, rapid progression to quadriparesis, respiratory failure, and high mortality. Several of these dogs had concurrent thymoma. In human patients, the acute fulminating form of MG is associated with high mortality, myasthenic crisis, and the highest percentage of thymomas.50 Similar to those in dogs, clinical signs of MG in cats are also variable.13, 24, 27, 61 In a recent study, the two most common clinical manifestations of MG observed in cats were generalized weakness without megaesophagus (28.6%) and generalized weakness associated with a cranial mediastinal mass (25.7%).61 Although megaesophagus and dysphagia developed as focal forms of MG (14.3%), the incidence was lower in cats than is typically observed in dogs. In this same study, MG was documented in ve hyperthyroid cats in which weakness developed 2 to 4 months after beginning treatment with the antithyroid drug methimazole. AChR antibodies were documented in all cats. A druginduced cause was postulated in which tolerance to self-AChR was reversibly broken by a pharmacologic agent. Diagnosis of Acquired Myasthenia Gravis As a result of the relatively common occurrence of acquired canine MG, all dogs presenting with generalized weakness, megaesophagus, or pharyngeal dysfunction should be tested for AChR antibodies as part of a minimum database. Serum should be collected before corticosteroid therapy is initiated because immunosuppressive doses of corticosteroids for longer than 7 to 10 days lower antibody concentrations (G.D. Shelton,

194

SHELTON

DVM, PhD, unpublished data). The gold standard for the diagnosis of immune-mediated MG in human beings35 and animals56, 58, 59 is the demonstration of serum autoantibodies against muscle AChRs by immunoprecipitation radioimmunoassay. This assay* is specic and sensitive, and it documents an autoimmune response against muscle AChRs.38 Although seronegative myasthenia occurs in approximately 2% of the dogs with generalized MG,59 false-positive results are rare. An AChR antibody titer greater than 0.6 nmol/L in dogs and greater than 0.3 nmol/L in cats is diagnostic of canine and feline MG. Although there is some cross-reactivity in antibody recognition of AChR between species, the assay is relatively species specic, and a canine or feline specic assay system should be used. Antibody titers in dogs are generally lower than in human beings, and low-titer positive results may be missed if human AChR is used as an antigen. A recent article has described an enzyme-linked immunosorbent assay method for the diagnosis of MG using oligopeptides from the canine AChR -subunit protein fraction.72 The results obtained from testing using this methodology must be interpreted with caution, because autoantibodies recognize native antigen structure and not denatured proteins, thus resulting in signicant numbers of potentially false-negative values. In addition, peptides produced in an Escherichia coli expression system may be contaminated with E. coli proteins that could potentially result in false-positive values.69 Other testing procedures for acquired MG lack sensitivity or specicity and may result in false-negative or false-positive results. The shortacting anticholinesterase drug edrophonium chloride (Tensilon) may be used to provide a presumptive diagnosis of acquired MG in dogs (0.10.2 mg/kg administered intravenously) and cats (0.250.5 mg total dose) while waiting for results of conrmatory testing. Overdose or use in a nonmyasthenic animal may cause salivation, retching, vomiting, and diarrhea, and 0.02 to 0.04 mg/kg of atropine sulfate should be given if this occurs. Pretreatment of cats with atropine before testing is suggested, because cats are sensitive to edrophonium chloride. As an alternative to edrophonium chloride, neostigmine methylsulfate (Prostigmin, 40 g/kg administered intramuscularly or 20 g/kg administered intravenously) may be used as a diagnostic aid for MG. Although a dramatic improvement in muscle strength after administration of the short-acting anticholinesterase drug provides a presumptive diagnosis of MG, a subjective improvement in muscle strength may be found in other myopathic or neuropathic disorders. Conversely, a lack of improvement in muscle strength does not eliminate a diagnosis of MG. A decrement in the amplitude of the compound muscle action potential in response to repetitive nerve stimulation also provides a presumptive diagnosis of MG64; however, there is a similar lack of
*Comparative Neuromuscular Laboratory, Basic Science Building, Room 2095, University of California, San Diego, La Jolla, CA 92093-0612. Telephone: 858 534-1537, Fax: 858 534-7319, e-mail: musclelab@ucsd.edu, located at: http://medicine.ucsd.edu/ vet_neuromuscular.

MYASTHENIA GRAVIS AND DISORDERS OF NEUROMUSCULAR TRANSMISSION

195

sensitivity and specicity in addition to the requirement for general anesthesia in a possibly critical patient. Single-ber electromyography is a sensitive method for detecting delayed or failed neuromuscular transmission, and a methodology has been established for the dog.23 Specicity, however, is lacking, with positive ndings in other disorders of the nerve, muscle, and NMJ.49 This procedure is also technically difcult and not performed routinely in clinical specialty neurology practices. Because acquired MG may be associated with other autoimmune and neoplastic disorders, a search for other concurrent diseases should also be made. Acquired MG may be associated with hypothyroidism,11 hypoadrenocorticism, thrombocytopenia, or hemolytic anemia58 or may present as a paraneoplastic syndrome associated with thymoma,1, 32 osteogenic sarcoma,41 cholangiocellular carcinoma,33 anal sac adenocarcinoma (G.D. Shelton, DVM, PhD, unpublished data), or cutaneous lymphoma.51 A complete blood cell count, serum chemistry prole, urinalysis, and thyroid evaluation should be performed in all cases. Thoracic radiographs should be routinely performed to evaluate for esophageal dilatation and cranial mediastinal masses. Third-degree heart block has also been found in some dogs with MG, thymoma, and polymyositis20; thus, a complete physical examination, including cardiac evaluation, should be performed. Treatment of Acquired Myasthenia Gravis Because of a lack of appropriately controlled and well-designed clinical trials in veterinary medicine, optimum treatments for acquired MG have not been established. A similar situation exists in human MG.26, 31 A critical factor that must be taken into account in the interpretation of any study of therapy for canine MG is the frequent occurrence of spontaneous remissions. In an effort to determine a natural course of the disease in dogs, 53 dogs were studied in which therapy was limited either to no treatment other than altered feeding procedures or to anticholinesterase drugs with or without altered feeding procedures in the absence of immunosuppression (G.D. Shelton, DVM, PhD, manuscript in press). Focal, generalized, and acute fulminating forms were included. AChR antibody titers were followed over the course of the study, which included the entire lifespan in several dogs. An important conclusion was that 47 of 53 (88.7%) dogs went into spontaneous immune and clinical remission at an average of 6.4 months after diagnosis (range: 118 months). The 6 dogs that did not go into remission developed neoplasia, including thymoma, melanosarcoma, and thyroglossal duct papillary cystadenocarcinoma 1 to 3 years after diagnosis. These ndings underlie the importance of well-controlled, double-blind studies in therapeutic trials in canine MG. The most important factors in obtaining a good clinical outcome in most cases of acquired canine MG are an early and accurate diagnosis

196

SHELTON

and good clinical judgment regarding the choice of appropriate therapies. Dedicated owners are also important, as treatment for MG needs to be continued for several months to years depending on the clinical form. Differentiation of vomiting from regurgitation and recognition of esophageal dilatation or pharyngeal weakness are critical. As in any dog with esophageal dilatation, altered feeding procedures, including elevation of food and water or placement of a gastrostomy tube, should be employed to facilitate adequate hydration, nutrition, and drug delivery. If there is a delay in identication of megaesophagus, inadequate nutrition and poor hydration may occur for several days, which could worsen the clinical status of the animal. Nutritional support can be expected to decrease morbidity and improve immune status.29 In cases of acute fulminating MG, parenteral nutrition may be the only option and should be instituted as early as possible. Referral of these patients to centers with intensive care facilities is optimal. Because clinical signs of MG are heterogeneous and variable, additional therapy should be determined by the severity of the disease. In a recent international conference on MG, a treatment algorithm for human MG was presented.28 A similar classication is followed in this article and includes the following categories: group 1 mild or focal MG, group 2 moderate generalized MG, and group 3 severe generalized or acute fulminating MG. Anticholinesterase agents are the cornerstone of therapy for MG, acting by prolonging the action of ACh at the NMJ and enhancing neuromuscular transmission. These drugs are used in all patient groups with MG. If an optimal response to therapy is obtained with these drugs, resulting in return of normal limb muscle strength, supportive care and anticholinesterase drugs may be all that is required for therapy. The dosage must be adjusted individually for each animal depending on the response to the drug and tolerance of the side effects. Available drugs include pyridostigmine bromide (Mestinon, 13 mg/kg administered orally twice daily or three times daily) and neostigmine bromide (Prostigmin, 2 mg/kg/d administered orally in divided doses to effect). Pyridostigmine bromide is available in syrup, tablet, and timed-release forms. The syrup form may be optimal for dosing in smaller breeds of dogs but should be diluted at a 50:50 ratio in water before use, because gastric irritation may result if it is given straight. For critical animals in which oral medication is not possible, constant rate infusion of pyridostigmine bromide (0.010.03 mg/kg/h) may be used until oral feedings are resumed or a feeding tube is placed. Side effects of anticholinesterase drugs include gastrointestinal signs (nausea, cramps, diarrhea) and excessive salivation and lacrimation. All such adverse effects may be reduced by administering small doses of atropine or having the animals take medication after meals when feasible. Overtreatment with anticholinesterase drugs poses another danger: excessive accumulation of ACh at the NMJ can result in weakness as a result of depolarization or desensitization of the postsynaptic membrane. Any increase in anticho-

MYASTHENIA GRAVIS AND DISORDERS OF NEUROMUSCULAR TRANSMISSION

197

linesterase medication that does not produce clear-cut improvement in muscle strength should be promptly reversed. If an optimal response to therapy is not obtained with supportive care and anticholinesterase drugs alone, corticosteroids may be added. Corticosteroids have been shown to be of benet in human MG28, 55 and also may improve the long-term prognosis in some cases of canine MG.10 Increased weakness often occurs early in the course of steroid treatment, however, requiring hospitalization and sometimes intensive medical care with respiratory support.54, 55 To prevent this initial steroid-induced weakness, low-dose prednisone therapy has been recommended in mild (group 1) and moderately affected (group 2) human myasthenic patients, beginning at 10 to 20 mg on alternate days to minimize any steroid adverse effects. If the response to therapy is not satisfactory after 2 weeks, prednisone can be increased by 10 mg every fth dose until symptoms improve or until a 60 mg (group 1) to 100 mg (group 2) total dose every other day is reached.28 This author has recommended a similar therapeutic approach in several mild to moderately affected myasthenic dogs (0.5 mg/kg every other day), and although a controlled clinical study has not been performed, the results seem encouraging. Relative contraindications for steroid therapy include severe obesity, diabetes mellitus, uncontrolled hypertension, gastrointestinal ulcerations, and ongoing infections or aspiration pneumonia. Other immunosuppressive agents such as azathioprine are only recommended for group 1 or group 2 if corticosteroids are contraindicated or if side effects are difcult to manage.28 Management of severe generalized MG (group 3) can be difcult and must be performed in intensive care facilities. In human patients, expensive short-term treatment modalities such as plasma exchange (plasmapheresis) and intravenous immunoglobulin may be used; however, because of the expense and technical difculty of performing these therapies, they are not routinely used in veterinary medicine. Ventilatory support is usually required, because intercurrent pulmonary infection (often caused by aspiration pneumonia) is present as a result of severe dysphagia. Respiratory failure may also be the most common cause of death in dogs with an acute fulminating myasthenic crisis.29, 30 Respiratory failure may result from ventilatory failure caused by weakness in the intercostal muscles or diaphragm or by severe aspiration pneumonia. If possible, cultures should be obtained from the respiratory tract by tracheal wash, and broad-spectrum intravenous antibiotics should be instituted immediately. Aminoglycosides and ampicillin should be avoided because of possible detrimental effects on neuromuscular transmission. Myasthenic crisis may be precipitated by concurrent infection or high doses of daily prednisone. Corticosteroids should be avoided initially in patients with overwhelming aspiration pneumonia. Once an infection has been controlled, corticosteroids or other immunosuppressive agents such as azathioprine9 can be added to the regimen if necessary. High-dose intravenous methylprednisolone therapy may be of benet in severe cases of MG.2, 37 In one human study, 2 g of methylprednisolone was given intravenously every 5 days to 15 patients with

198

SHELTON

exacerbation of generalized MG. Satisfactory improvement without exacerbation of muscle weakness occurred in 10 of 15 patients.2

Monitoring the Course of Acquired Myasthenia Gravis Although a positive AChR antibody titer is diagnostic of acquired MG, there is poor correlation between the severity of the disease and the antibody concentration. In the absence of immunosuppression, determination of serial AChR antibody titers in an individual animal is a good indicator of disease status and should help to determine duration of treatment. As long as AChR antibody titers are positive, treatment should be continued. There has been excellent correlation between resolution of clinical signs, including megaesophagus, and return of AChR antibody titers to less than 0.6 nmol/L (G.D. Shelton, DVM, PhD, manuscript in press).

Seronegative Myasthenia Gravis Seronegative MG has been described in human beings,2, 43, 53 and numbers vary between 6% and 34% of MG patients. Seronegative and seropositive patients manifest similar clinical features. Criteria used to classify dogs as having seronegative MG include consistent clinical signs, consistent pharmacologic (positive edrophonium response) and electrophysiologic (decrement) ndings, normalization of limb muscle weakness after anticholinesterase therapy, and at least two negative serum AChR antibody titers by radioimmunoassay. Seroconversion may occur; thus, antibody titers should be repeated 1 to 2 months after a negative AChR antibody titer. Approximately 2% of dogs with generalized MG are seronegative.58 The percentage of dogs with seronegative focal MG has not been determined. Possible explanations for seronegative MG include the following: (1) antibodies are directed against non-AChR end-plate determinants43; (2) antibodies are directed against the toxin binding site such that patients with antibodies to this site would seem to be seronegative; (3) antibodies are bound to the end plates without detectable circulating serum antibodies (antigen excess); and (4) antibodies are directed against antigenic determinants that may be lost during the AChR extraction procedure. In a recent study, autoantibodies were detected against a previously unidentied muscle-specic receptor tyrosine kinase, MuSK, in approximately 70% of human seronegative patients.22 Similar antibodies were not detected in seropositive patients. Studies are currently underway to determine if similar autoantibodies occur in canine seronegative MG.

MYASTHENIA GRAVIS AND DISORDERS OF NEUROMUSCULAR TRANSMISSION

199

Other Serologic Tests In human patients with MG, autoantibodies against striated muscle proteins have been described, including antibodies against myosin, actin, -actinin,71 titin,19 and the sarcoplasmic reticulum. These have been collectively referred to as striational antibodies (StrAbs). Because these antigens are located in the muscle cytoplasm and are not normally accessible to circulating antibodies, they are believed to be nonpathogenic. Positive assays for StrAbs in human beings may support a clinical diagnosis of acquired MG when tests for AChR antibodies are negative.35 StrAbs are detected in 80% of human MG patients with thymoma, in approximately 24% of patients having thymoma without clinical signs of MG, and in 30% of adult MG patients without thymoma. Although StrAbs have been reported in canine MG18 and the author has observed StrAbs in canine patients with thymoma, the actual incidence has not yet been determined. Recently, antibodies against the ryanodine receptor (RyR) have been described in human patients in association with MG and thymoma44, 45 and in late-onset MG.65 The presence of autoantibodies against RyR was associated with a severe form of thymoma-related MG and higher mortality. The RyR is a skeletal muscle calcium release channel important in muscle contraction and in the mechanism of excitationcontraction coupling. Autoantibodies against RyR have also been documented in dogs with thymoma and older onset MG.63 Similar to the results of the human studies, the presence of antibodies against RyR in dogs was associated with more severe clinical weakness.63 The presence of RyR antibodies that play a functional role may begin to explain the lack of correlation between the AChR antibody titer and severity of muscle weakness.

Thymoma-Associated Myasthenia Gravis All dogs or cats with a cranial mediastinal mass, even in the absence of muscle weakness, should be tested for the presence of AChR antibodies and StrAbs before surgical mass removal. Weakness may become clinical after the surgery, and knowing the antibody status before surgery should aid in therapeutic management. Although thymomas may be slow-growing tumors, therapy needs to address the space-occupying, invasive, or metastatic potential of the tumor and the manifestations of MG.32 In a small number of cases followed by the author, complete removal of the tumor was associated with normalization of the AChR antibody titer and resolution of clinical signs. If the mass was not completely removed, the antibody titer did not decrease, and if there was regrowth of the tumor, the AChR antibody titer again became elevated (G.D. Shelton, DVM, PhD, unpublished data). In a single case report, surgical removal of a thymoma resulted in rapid resolution of

200

SHELTON

megaesophagus and decreased serum AChR antibody concentration.34 The dog was clinically normal until the thymoma recurred 6 months after surgery. Although the AChR antibody titer decreased, it did not return to the normal range, suggesting that the tumor was not completely excised. Clearly, a controlled study needs to be performed to determine the optimum therapeutic approach for thymoma and MG in dogs and cats. Feline Myasthenia Gravis As the spectrum of clinical signs in cats with MG is being recognized, an increasing number of cats with acquired MG are being diagnosed.13, 61 An increased relative risk for acquired MG compared with that of mixed-breed cats was identied in Abyssinian and Somali cats.61 Although there are several similarities in the clinical manifestations of acquired MG in dogs and cats, important differences have also been observed. The greater number of thymomas occurring in myasthenic cats highlights the importance of evaluating thoracic radiographs in all cats with MG, even in the absence of clinical signs of respiratory distress or esophageal dysfunction. Acquired drug-induced MG should also be considered in hyperthyroid cats that become weak after initiation of treatment with methimazole.61, 62 Long-term studies with serial AChR antibody titers are not available in cats; thus, unlike the case in dogs, the natural course of the disease is not known. Although myasthenic cats can be treated successfully with anticholinesterase drugs,13, 27 it is the impression of this author that cats generally respond better to immunosuppression than to anticholinesterase therapy. Unlike the case in dogs, exacerbation of muscle weakness and other unwanted side effects may not occur in myasthenic cats treated with high doses of corticosteroids. Important Dos and Donts After studying acquired MG in dogs and cats for over 15 years, a few pearls of wisdom have been acquired that this author believes are of utmost importance in the treatment of acquired MG: 1. Make sure regurgitation is differentiated from vomiting. Vomiting can result in a wrong diagnostic pathway and waste precious time in obtaining the correct diagnosis. 2. Make every attempt to reach a correct diagnosis as soon as possible. Trial and error therapy may result in delays in reaching the correct diagnosis or possibly make obtaining a correct diagnosis difcult. 3. Know which drugs are contraindicated for use in myasthenic patients.

MYASTHENIA GRAVIS AND DISORDERS OF NEUROMUSCULAR TRANSMISSION

201

4. Recommend to the owner or breeder not to breed any myasthenic animal. 5. Spay myasthenic female dogs and cats as soon as possible after MG is under control, because heat cycles and pregnancy can exacerbate active MG. 6. Be careful not to overvaccinate, because vaccinations have been shown to exacerbate active MG (G.D. Shelton, DVM, PhD, unpublished data). Although mortality for canine MG is still unacceptably high, the information recently obtained in a study of the natural course of the disease in dogs is encouraging (G.D. Shelton, DVM, PhD, manuscript in press). As shown in this recent study of 53 dogs treated with just supportive care or with anticholinesterase drugs, 87% of myasthenic dogs went into spontaneous remission without reoccurrence of clinical weakness. It is the opinion of this author that the unacceptably high mortality described in other studies5, 10 is likely a result of a delay in reaching an accurate diagnosis, a delay in the initiation of appropriate therapy, severe aspiration pneumonia, or the use of high doses of corticosteroids early in the course of therapy. OTHER DISORDERS OF NEUROMUSCULAR TRANSMISSION A summary of the main clinical, neurologic, and diagnostic differentiating features of the four primary causes of lower motor neuron tetraparesis in the dog are shown in Table 1 of the article on acquired canine peripheral neuropathies by Cuddon in this issue. Of the four primary causes, three are associated with disorders of neuromuscular transmission. Coonhound paralysis or acute canine polyneuropathy is described elsewhere in this issue. Acute fulminating MG was discussed earlier in this article. The remainder of this article focuses on the other main causes of lower motor neuron tetraparesis in dogs resulting from neuromuscular transmission abnormalities, including tick paralysis and botulism, organophosphate (OP) intoxication in the cat, and drug-induced neuromuscular blockade. Presynaptic Disorders: Tick Paralysis Tick paralysis is a rapidly ascending lower motor neuron paralysis resulting from neuromuscular blockade that occurs after attachment of a tick. A salivary neurotoxin is secreted by ticks of the Dermacentor and Ixodes species that interferes in a temperature-dependent way with ACh release, resulting in impaired neuromuscular transmission and clinical weakness.7 In the United States, the wood ticks Dermacentor variabilis and Dermacentor andersoni are incriminated most often, although in Australia,

202

SHELTON

Ixodes holocyclus is most commonly involved.16 Diagnosis is conrmed by nding a tick attached to the affected animal and noting rapid improvement after removal. With Dermacentor spp, recovery occurs after tick removal or after dips in appropriate insecticide solutions. With Ixodes spp, clinical signs tend to be more severe and include autonomic disturbances. In addition to tick removal and general nursing care, hyperimmune serum and -adrenergic blocking agents enhance the chances of recovery.16 Presynaptic Disorders: Botulism Ingestion of the type C neurotoxin of Clostridium botulinum contained in carrion and spoiled food can result in the acute onset of diffuse lower motor neuron dysfunction. The severity of dysfunction may range from severe and fatal tetraplegia and hyporeexia to mild weakness depending on the amount of toxin ingested and the species of animal affected. Thoracic radiographs may reveal megaesophagus and aspiration pneumonia. Botulinum toxin has been shown to bind selectively to presynaptic receptors at the nerve terminus and then is translocated into the nerve terminal.12 Neuromuscular blockade is the result of inhibition of presynaptic ACh release from the nerve terminals of cholinergic bers. The diagnosis is conrmed by detection of the organism in ingested material, serum, vomit, and feces; by a neutralization test in small rodents; or by in vitro tests that measure toxin antigenicity rather than toxicity.3 Although dogs have been thought to be somewhat resistant to botulism, there are reports of type C botulism conrmed by detection of toxin in the serum and feces of affected dogs using a mouse bioassay system.4, 8 There are no natural cases reported in cats. Treatment of botulism is usually supportive, with mildly or moderately affected dogs recovering over a period of several days. Intensive care may be required, including ventilatory support and management of dysphagia. Frequent turning should be performed, and good padding should be used to prevent pressure sores. Administration of laxatives and enemas may help to remove unabsorbed toxin from the gastrointestinal tract if the ingestion was recent. Oral antibiotics are of no benet, because gastrointestinal colonization does not occur. Administration of C. botulinum antitoxin has not been benecial. Type Cspecic antitoxin is not generally available, and administration of trivalent antitoxin (types A, B, and E) is not likely to be effective. Further, antitoxin administration only helps to inactivate circulating unbound toxin and not toxin already xed at the site of neuromuscular junction damage.16 Complete recovery should occur within 1 to 3 weeks. Postsynaptic Disorders: Organophosphate and Carbamate Toxicity Organophosphates and carbamates, which are common active ingredients in household and agricultural insecticide products, are long-acting

MYASTHENIA GRAVIS AND DISORDERS OF NEUROMUSCULAR TRANSMISSION

203

anticholinesterases that irreversibly bind AChE in nervous tissue and muscle, permitting accumulation of ACh and allowing continuous cholinergic stimulation. ACh accumulates at central, muscarinic, and nicotinic cholinergic synapses, resulting in clinical signs that include autonomic nervous system overstimulation and neuromuscular dysfunction. Cats are extremely susceptible to these compounds.70 Historical features regarding misuse of insecticides are helpful in reaching the diagnosis. Serum cholinesterase concentrations may be measured, although even routine use of insecticides depresses these concentrations. Clinical signs of chronic OP intoxication include a stiff rigid gait, muscle tremors, and fasciculation. A peripheral neuropathy may occur in cats some time after exposure.46 Fenthion toxicity differs from classic OP poisoning, with weakness predominating and little evidence of autonomic dysfunction. Chronic exposure to fenthion may occur before clinical signs appear, and the onset of signs may be delayed.46 Plasma cholinesterase concentrations are markedly depressed, often to 10% of normal. Treatment includes reducing further absorption in acute cases by bathing or gastric lavage as appropriate. Atropine sulfate (0.2 mg/kg total, with one quarter administered intravenously and the remaining three quarters administered subcutaneously on an as-needed basis) is used to counteract the parasympathetic signs. Pralidoxime chloride (2PAM or Protopam chloride; 1015 mg/kg administered intramuscularly or subcutaneously every 812 hours until recovery; discontinue after three doses if no response)21 releases the AChE from the OP compound and is indicated in OP toxicity. It should not be used in carbamate toxicity. Pralidoxime chloride has also been useful in cases of chlorpyrifos toxicity in cats.25 Diphenhydramine has been recommended to relieve muscle weakness and tremors in fenthion toxicity.6 In this case, absorption of the toxin is rapid; thus, attempts to remove it by bathing are unlikely to be useful. Weakness associated with chronic OP toxicity may last 2 to 4 weeks; however, most patients fully recover with aggressive nursing care. Drug-Induced Neuromuscular Blockade Several drugs have been shown to reduce the safety margin of neuromuscular transmission, including aminoglycoside antibiotics, antiarrhythmic agents, phenothiazines, methoxyurane, and magnesium, given parenterally or in cathartics.57 Unless overdosage occurs or there is impairment of renal or hepatic elimination, overt signs of muscle weakness have not been documented. It is important to remember, however, that these agents can potentiate neuromuscular blocking agents used during surgical procedures and may worsen or unmask preexisting disorders of neuromuscular transmission. The use of these agents should be avoided in MG patients. In human beings, penicillamine can induce autoimmune MG in a proportion of patients who are receiving the drug for other autoimmune

204

SHELTON

conditions.68 This side effect has not yet been reported in veterinary medicine. The MG gradually disappears when the drug is discontinued. A similar reversible drug-induced autoimmune MG has been documented in hyperthyroid cats receiving methimazole.62

References
1. Aronsohn MG, Schunk KL, Carpenter JL, et al: Clinical and pathologic features of thymoma in 15 dogs. JAVMA 184:13551362, 1984 2. Arsura E, Brunner NG, Namba T, et al: High-dose intravenous methylprednisolone in myasthenia gravis. Arch Neurol 42:11491153, 1985 3. Barsanti JA: Botulism. In Greene CE (ed): Infectious Diseases of the Dog and Cat, ed 2. Philadelphia, WB Saunders, 1998, pp 263-267 4. Barsanti JA, Walser M, Hatheway CL, et al: Type-C botulism in American foxhounds. JAVMA 172:809813, 1978 5. Bartges JW, Hansen D, Hardy RM: Outcome of 30 cases of acquired myasthenia gravis in dogs (19821992) [abstract]. J Vet Intern Med 11:144, 1997 6. Clemmons RM, Meyer DJ, Sundolf SF, et al: Correction of organophosphate-induced neuromuscular blockade by diphenhydramine. Am J Vet Res 45:21672169, 1984 7. Cooper BJ, Spence I: Temperature-dependent inhibition of evoked acetylcholine release in tick paralysis. Nature 263:693695, 1976 8. Cornelissen JMM, Haagsma J, Van Nes JJ: Type-C botulism in ve dogs. J Am Anim Hosp Assoc 21:401404, 1985 9. Dewey CW, Coates JR, Ducote JM, et al: Azathioprine therapy for acquired myasthenia gravis in ve dogs. J Am Anim Hosp Assoc 35:396402, 1999 10. Dewey CW, Bailey CS, Shelton GD, et al: Clinical forms of acquired myasthenia gravis in dogs: 25 cases (19881995). J Vet Intern Med 11:5057, 1997 11. Dewey CW, Shelton GD, Bailey CS, et al: Neuromuscular dysfunction in ve dogs with acquired myasthenia gravis and presumptive hypothyroidism. Prog Vet Neurol 6:117123, 1995 12. Dolly JO, Black J, Williams RS, et al: Acceptors for botulinum neurotoxin reside on motor nerve terminals and mediate internalization. Nature 307:457460, 1984 13. Ducote JM, Dewey CW, Coates JR: Clinical forms of acquired myasthenia gravis in cats. Compend Contin Educ Pract Vet 21:440448, 1999 14. Elmqvist D, Quastel DMJ: A quantitative study of end-plate potentials in isolated human muscle. J Physiol (Lond) 178:505529, 1965 15. Engel AG: Myasthenic syndromes. In Engel AG, Franzini-Armstrong C (eds): Myology. New York, McGraw-Hill, 1994, pp 17981835 16. Farrow BRH: Tick paralysis and botulism. In Proceedings of the Sixth Amercian College of Veterinary Internal Medicine Forum, Washington, DC, 1988, pp 6163 17. Flagstad A, Trojaborg W, Gammeltoft S: Congenital myasthenic syndrome in the dog breed Gammel Dansk Honsehund: Clinical, electrophysiological, pharmacological and immunological comparison with acquired myasthenia gravis. Acta Vet Scand 30:89 102, 1989 18. Garlepp MJ, Kay PH, Farrow BR, et al: Autoimmunity in spontaneous myasthenia gravis in dogs. Clin Immunol Immunopathol 31:301306, 1984 19. Gautel M, Lakey A, Barlow DP, et al: Titin antibodies in myasthenia gravis: Identication of a major immunogenic region of titin. Neurology 43:15811585, 1993 20. Hackett TB, Van Pelt DR, Willard MD, et al: Third degree atrioventricular block and acquired myasthenia gravis in four dogs. JAVMA 206:11731176, 1995 21. Hanson SR, Curry-Galvin EA: Organophosphate and carbamate toxicity. In Tilley LP, Smith FWK (eds): The 5-Minute Veterinary Consult. Canine and Feline, ed 2. Philadelphia, Lippincott Williams & Wilkins, 2000, pp 10181019 22. Hoch W, McConville J, Helms S, et al: Auto-antibodies to the receptor tyrosine kinase

MYASTHENIA GRAVIS AND DISORDERS OF NEUROMUSCULAR TRANSMISSION

205

23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49.

MuSK in patients with myasthenia gravis without acetylcholine receptor antibodies. Nat Med 7:365368, 2001 Hopkins AL, Howard JF, Wheeler SJ, et al: Stimulated single bre electromyography in normal dogs. J Small Anim Pract 34:271276, 1993 Indrieri RJ, Creighton SR, Lambert EH, et al: Myasthenia gravis in two cats. JAVMA 182:5760, 1983 Jaggy A, Oliver JE: Chlorpyrifos toxicosis in two cats. J Vet Intern Med 4:135139, 1995 Jaretzki A III, Barohn RJ, Ernstoff RM, et al: Myasthenia gravis. Recommendations for clinical research standards. Neurology 55:1623, 2000 Joseph RJ, Carrillo JM, Lennon VA: Myasthenia gravis in the cat. J Vet Intern Med 2:7579, 1988 Keesey J: A treatment algorithm for autoimmune myasthenia in adults. Ann NY Acad Sci 841:753768, 1998 King LG: Medical management of the critical myasthenic patient. In Proceedings of the 16th American College of Veterinary Internal Medicine Forum, San Diego, 1998, pp 311-313 King LG, Vite CH: Acute fulminating myasthenia gravis in ve dogs. JAVMA 212:830 834, 1998 Kissel JT, Franklin GM: Treatment of myasthenia gravis. A call to arms. Neurology 55:34, 2000 Klebanow ER: Thymoma and acquired myasthenia gravis in the dog: A case report and review of 13 additional cases. J Am Anim Hosp Assoc 28:6369, 1992 Krotje LJ, Fix AS, Potthoff AD: Acquired myasthenia gravis and cholangiocellular carcinoma in a dog. JAVMA 197:488490, 1990 Lainesse MFC, Taylor SM, Myers SL, et al: Focal myasthenia gravis as a paraneoplastic syndrome of canine thymoma: Improvement following thymectomy. J Am Anim Hosp Assoc 32:111117, 1996 Lennon VA: Serologic prole of myasthenia gravis and distinction from the LambertEaton myasthenic syndrome. Neurology 48(suppl 5):S2327, 1997 Lennon VA, Lambert EH, Palmer AC, et al: Acquired and congenital myasthenia gravis in dogs: A study of 20 cases. In Satoyoshi E (ed): Myasthenia GravisPathogenesis and Treatment. Tokyo, Toyko University Press, 1981, pp 1454 Lindberg C, Andersen O, Lefvert AK: Treatment of myasthenia gravis with methylprednisolone pulse: A double blind study. Acta Neurol Scand 97:370373, 1998 Lindstrom JM, Shelton D, Fujii Y: Myasthenia gravis. Adv Immunol 42:233284, 1988 Maselli RA, Mass DP, Distad BJ, et al: Anconeus muscle: A human muscle preparation suitable for in-vitro microelectrode studies. Muscle Nerve 14:11891192, 1991 Miller LM, Lennon VA, Lambert EH, et al: Congenital myasthenia gravis in 13 smooth fox terriers. JAVMA 182:694698, 1983 Moore AS, Madewell BR, Cardinet GH III, et al: Osteogenic sarcoma and myasthenia gravis in a dog. JAVMA 197:226227, 1990 Mora M, Lambert EH, Engel AG: Synaptic vesicle abnormality in familial infantile myasthenia. Neurology 37:206214, 1987 Mossman S, Vincent A, Newsom-Davis J: Myasthenia gravis without acetylcholinereceptor antibody: A distinct disease entity. Lancet 1:116118, 1986 Mygland A, Tysnes OB, Matre R, et al: Ryanodine receptor autoantibodies in myasthenia gravis patients with a thymoma. Ann Neurol 32:589591, 1992 Mygland A, Aarli JA, Matre R, et al: Ryanodine receptor antibodies related to severity of thymoma associated myasthenia gravis. J Neurol Neurosurg Psychiatry 57:843 846, 1994 Nafe LA: Selected neurotoxins. Vet Clin North Am Small Anim Pract 18:593604, 1990 Oda K, Lambert EH, Lennon VA, et al: Congenital canine myasthenia gravis. I. Decient junctional acetylcholine receptors. Muscle Nerve 7:705716, 1984 Oda K, Lennon VA, Lambert EH, et al: Congenital canine myasthenia gravis. II. Acetylcholine receptor metabolism. Muscle Nerve 7:717724, 1984 Oh SJ, Kim DE, Kuruoglu R, et al: Diagnostic sensitivity of the laboratory tests in myasthenia gravis. Muscle Nerve 15:720724, 1992

206

SHELTON

50. Osserman KE, Genkins G: Studies in myasthenia gravis: Review of a twenty-year experience in over 1200 patients. Mt Sinai J Med 38:497537, 1971 51. Ridyard AE, Rhind SM, French AT, et al: Myasthenia gravis associated with cutaneous lymphoma in a dog. J Small Anim Pract 41:348351, 2000 52. Robertson WC, Chun RWM, Kornguth SE: Familial infantile myasthenia. Arch Neurol 37:117119, 1980 53. Sanders DB, Andrews PI, Howard JF, et al: Seronegative myasthenia gravis. Neurology 48(suppl 5):S4045, 1997 54. Seybold ME: Update on myasthenia gravis. Hospital Medicine 7188, April 1991 55. Seybold ME, Drachman DB: Gradually increasing doses of prednisone in myasthenia gravis. Reducing the hazards of treatment. N Engl J Med 290:8184, 1974 56. Shelton GD: Acquired myasthenia gravis: What we have learned from experimental and spontaneous animal models. Vet Immunol Immunopathol 69:239249, 1999 57. Shelton GD: Disorders of neuromuscular transmission. Seminars Vet Med Surg (Small Anim) 4:126132, 1989 58. Shelton GD: Myasthenia gravis: Lessons from the past 10 years. J Small Anim Pract 39:368372, 1998 59. Shelton GD: Myasthenia gravis: Laboratory diagnosis and predictive factors. In Proceedings of the 16th Annual American College of Veterinary Internal Medicine Forum, San Diego, 1998, pp 309310, 1998 60. Shelton GD, Schule A, Kass PH: Risk factors for acquired myasthenia gravis in dogs: 1,154 cases (19911995). JAVMA 211:14281431, 1997 61. Shelton GD, Ho M, Kass PH: Risk factors for acquired myasthenia gravis in cats: 105 cases (19861998). JAVMA 216:5557, 2000 62. Shelton GD, Joseph R, Richter K, et al: Acquired myasthenia gravis in hyperthyroid cats on Tapazole therapy [abstract]. J Vet Intern Med 11:120, 1997 63. Shelton GD, Skeie GO, Kass PH, et al: Titin and ryanodine receptor autoantibodies in dogs with thymoma and late-onset myasthenia gravis. Vet Immunol Immunopathol 78:97105, 2001 64. Sims MH, McLean RA: Use of repetitive nerve stimulation to assess neuromuscular function in dogs. A test protocol for suspected myasthenia gravis. Prog Vet Neurol 1:311319, 1990 65. Skeie GO, Mygland A, Aarli JA, et al: Titin antibodies in patients with late onset myasthenia gravis: Clinical correlations. Autoimmunity 20:99104, 1995 66. Soliven BC, Lange DJ, Penn AS, et al: Seronegative myasthenia gravis. Neurology 38:514517, 1988 67. Trojaborg W, Flagstad A: A hereditary neuromuscular disorder in dogs. Muscle Nerve Suppl 5:S3038, 1982 68. Vincent A, Newson-Davis J: Acetylcholine receptor antibody characteristics in myasthenia gravis. 2. Patients with penicillamine-induced myasthenia or myasthenia of recent onset. J Clin Exp Immunol 49:266272, 1982 69. Voltz R, Kamm C, Padberg F, et al: Highly puried oligo-His tagged human recombinant 1-AChR is immunogenic in vivo and suitable for T cell stimulation in vitro in experimental and human myasthenia gravis. J Neuroimmunol 80:131136, 1997 70. Wheeler SJ: Disorders of the neuromuscular junction. Prog Vet Neurol 2:129135, 1991 71. Williams CL, Lennon VA: Thymic B lymphocyte clones from patients with myasthenia gravis secrete monoclonal striational autoantibodies reacting with myosin, -actinin, or actin. J Exp Med 164:10431059, 1986 72. Yoshioka T, Uzuka Y, Tanabe S: Molecular cloning of the canine nicotinic acetylcholine receptor -subunit gene and development of the ELISA method to diagnose myasthenia gravis. Vet Immunol Immunopathol 72:315324, 1999 Address reprint requests to G. Diane Shelton, DVM, PhD Department of Pathology University of California, San Diego La Jolla, CA 920930612 e-mail: gshelton@ucsd.edu