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J Neuroimmunol. 2012 Sep 15;250(1-2):94-8. doi: 10.1016/j.jneuroim.2012.05.011. Epub 2012 Jun 9.

Anti-MuSK- and anti-AChR-positive myasthenia gravis induced by d-penicillamine.

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  • 1Department of Pharmacy, University of Patras, GR 26500, Patras, Greece.



Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction usually caused by antibodies to the nicotinic acetylcholine receptor (AChR) and occasionally to muscle-specific kinase (MuSK). D-penicillamine is a therapeutic agent for several diseases, but can also induce a number of immune-mediated disorders, including MG, as a side-effect. In most patients with D-penicillamine-induced MG, anti-AChR antibodies are detected, but the presence of anti-MuSK antibodies has not been reported previously.


The case reported was a female patient who presented with myasthenic symptoms after D-penicillamine administration for scleroderma.


Both anti-AChR and anti-MuSK antibodies were identified in the patient's serum. The anti-MuSK antibodies were of the IgG4 subclass, as in idiopathic MG. Both types of antibody gradually disappeared after discontinuation of D-penicillamine. A significant improvement in symptoms was observed and the patient gradually became free of MG symptoms, without requiring any treatment for MG. Another four double-positive (anti-AChR and anti-MuSK antibodies) patients were identified during a retrospective study, but none had been treated with D-penicillamine.


D-penicillamine can cause anti-AChR and anti-MuSK antibody-positive MG, a rare phenomenon which is reversed after discontinuation of D-penicillamine treatment.

Copyright © 2012 Elsevier B.V. All rights reserved.

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