Pneumocystis jirovecii Pneumonia in Neurologic Disorders: Is Prophylaxis Necessary?

BACKGROUND: The incidence of Pneumocystis jirovecii pneumonia (PJP) in patients with underlying neurologic conditions is not well established, and the necessity of PJP prophylaxis for immunocompromised patients with neurologic disorders is uncertain. METHODS: Single-center retrospective analysis of non-HIV PJP patients at a tertiary referral center from 2007 to 2016 to determine the incidence of PJP in patients with primary neurologic disorders. RESULTS: The study included 142 patients with PJP without HIV. Twenty patients had primary neurologic diagnoses, and 122 had non-neurologic conditions. Associated neurologic diagnoses included brain malignancies (N = 14), myasthenia gravis (MG) (N = 2), myopathy (N = 2), neuromyelitis optica (NMO) (N = 1), and CNS vasculitis (N = 1). Estimated incidences of PJP were 0.7% for patients with NMO and 0.3% for patients with MG for the 10-year study period, whereas 4.6% of patients with NMO and 3.8% of patients with MG were placed on PJP prophylaxis. A survey of 24 neurologists who prescribe immunotherapy or chemotherapy confirmed an infrequent occurrence of PJP in their practice. Malignancy or parenchymal organ failure was present in 90% of neurologic patients with PJP, and coexisting infections occurred in 45%. CONCLUSIONS: The overall incidence of PJP in patients with non-neoplastic neurologic disorders is exceedingly low, raising doubt about the value of routine PJP prophylaxis in neurologic patients outside neuro-oncology. PJP infection occurs frequently in patients with malignancy or parenchymal organ failure, indicating that overall health status may serve as a predisposing factor for PJP.

Direct comparison of median and ulnar repetitive nerve stimulation in generalized myasthenia gravis.

INTRODUCTION/AIMS: Ulnar nerve repetitive nerve stimulation (RNS) has been traditionally used in the electrophysiological evaluation of myasthenia gravis (MG). However, its low diagnostic sensitivity remains a limitation. Existing data may suggest that median nerve RNS outperforms that of the ulnar nerve, but a direct comparison is currently lacking. The aim of this study was to directly compare the diagnostic yields between median and ulnar nerve RNS in patients with generalized MG. METHODS: We performed a retrospective analysis of patients with MG who underwent median and ulnar nerve RNS at a single tertiary center. RESULTS: RNS studies of median nerve recording from the abductor pollicis brevis and ulnar nerve recording from the adductor digiti minimi were completed in 28 patients with generalized MG. Abnormal RNS was more frequently observed in the median compared with the ulnar nerve (60.7% vs 35.7%, P = .046). The average magnitude of decrement was higher in the median nerve compared with the ulnar nerve (17.3% vs 9.6%, P = .017). Differences between the median and ulnar nerve RNS studies were restricted to patients with mild manifestations (Myasthenia Gravis Foundation of America class II). DISCUSSION: Median nerve RNS has superior diagnostic sensitivity as compared with ulnar nerve RNS in the assessment of mild generalized MG.

Comitant Ocular Deviation in Myasthenia Gravis.

BACKGROUND: Occurrence of comitant ocular deviation in myasthenia gravis (MG) is not well described. METHODS: A retrospective analysis of patients with ocular or generalized MG evaluated at a neuro-ophthalmology clinic for a 6-year period. Comitant ocular deviation was defined as magnitude of deviations in all planes varying by <20% from the measurement in the primary position. RESULTS: Among the 120 patients included, 89 patients had ocular and 31 patients generalized MG. At the initial strabismus testing, comitant ocular deviation was present in 27 (22.5%) patients. Among the 16 patients who had a follow-up, ocular deviation remained comitant in 6 patients and converted to incomitant or no ocular deviation in 10 patients. An additional 7 patients demonstrated comitant ocular deviation at follow-up. Brain MRI was performed in 18 patients with comitant ocular deviation, and none showed abnormalities in the brainstem or cerebellum. CONCLUSION: Comitant ocular deviation can be an ocular manifestation of MG. Its presence does not necessarily indicate a central etiology in patients with MG neither excluding a MG diagnosis.