VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
JOURNAL OF MEDICINE
Copyright © 2000 by
PJD Publications Limited
Research Communications
Westbury, NY 11590-0966 USA
ENHANCEMENT OF NORADRENERGIC NEURAL
TRANSMISSION: AN EFFECTIVE THERAPY OF
MYASTHENIA GRAVIS
A REPORT ON 52 CONSECUTIVE PATIENTS
Fuad. Lechin1,2, Bertha van der Dijs1,2, Betty Pardey-Maldonado1,
Eduardo Jahn1, Vladimir Jimenez1, Beatriz Orozco1,
Scarlet Baez2 and Marcel E. Lechin3
Sections of 1Neuropharmacology and 2Clinical Neurochemistry,
Instituto de Medicina Experimental, Universidad Central de Venezuela.
3
Texas A & M University, School of Medicine,
College Station, TX, USA
Key Words: Myasthenia gravis and Th2 immune disorders, myasthenia
gravis treatment, noradrenergic neural transmission, sympathetic
activity and autoimmune disorders, serotonin and autoimmune
disorders.
Subjects: Patients with myasthenia gravis.
Abbreviations: f5HT = free-serotonin, LC = locus coeruleus, MG =
myasthenia gravis, NA = noradrenergic, SLE = systemic lupus
erythematous.
Abstract
Neurochemical, neuroautonomic and neuropharmacological
assessments carried out on all our myasthenia gravis (MG) patients
showed that they presented a neural sympathetic deficit plus excessive
adrenal-sympathetic activity. These abnormalities were registered during
333
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
the basal (supine-resting) state, as well as after several stress tests
(orthostasis, exercise, oral glucose and buspirone). In addition, MG
patients showed increased levels of free-serotonin (f5HT) in the plasma,
supposedly associated with the increased platelet aggregability which we
found in all MG patients. As the above trio of neurochemical disorders
(low noradrenergic-activity + high adrenergic-activity + increased f-5HT
plasma levels) is known to favor Th-1 immunosuppression + Th-2
predominance, we outlined a neuropharmacological strategy for
reverting the above neurochemical disorder. This treatment provoked
sudden (acute), and late sustained improvements. Acute effects have
been attributed to the increase of alpha-1 activity at the spinal
motoneuron level. Late improvements always paralleled a significant
normalization of immunological disorders. Complete normalization was
registered only in non-thymectomized MG patients.
Introduction
In a preliminary, report we published the successful therapeutic
results obtained in eight myasthenia gravis (MG) patients receiving
neuropharmacological treatment (Lechin, van der Dijs et al., 1997a). In
the present study, we presented the results obtained in a series of 52
consecutive MG patients given the same therapy aimed at enhancing
noradrenergic (NA) neural transmission.
The rationale of our neuropharmacological approach rests on two
fundamental findings: first, all our MG patients showed a neurochemical
deficiency of central and peripheral noradrenergic (NA) activity (Lechin,
van der Dijs et al., 1985a, 1985b, 1990a, 1990b, 1995a, 1995b, 1996a,
1996b, 1996c, 1996e), and second, those MG patients who had not
previously
been
submitted
to
surgical
and/or
chemical
immunosuppression all showed an immunological Th-2 disorder,
confirming data obtained by many other researchers (Barnard, Mahon et
al., 1996; Faxvaag, Espevik et al., 1995; Romagnani, 1996). We decided,
therefore, to attempt a two-pronged neuropharmacological therapy
addressed to increasing NA neural, but not adrenal, sympathetic activity.
This decision was adopted for the following reasons: it has been
exhaustively demonstrated that NA neural activity stimulates the
immune system, in particular macrophages and Th-1 cytokines, whereas
adrenal glands sympathetic activity displays opposite effects and, in
addition, is associated with excessive humoral immunity (Th-2 profile)
and Th-2 cytokines (Kouassi, Li et al., 1990; Madden, Moynihan et al.,
334
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
1994b; Spengler, Allen et al., 1990). Neuropharmacological
manipulations were designed to stimulate the locus coeruleus (LC) NA
neurons. Further-more, considering that all our MG patients showed high
free serotonin in plasma rather than in platelets (raised f-5HT plasma
levels), possibly associated with the increased platelet aggregability that
all them presented, we assumed that eliminating the well-known Th-1
immunosuppressant effects of f-5HT would aid in reverting the
autoimmune disorders underlying MG disease (Fuchs, Campbell et al.,
1988; Jackson, Walker et al., 1998; Paegelow, Werner et al., 1985;
Sternberg, Wedner et al., 1987; Walker and Codd, 1985; Warren, Kane
et al., 1990) also included into the Th-2 autoimmune diseases
(MokhtarianShirazian et al., 1993).
It has been exhaustively demonstrated that peripheral neural
sympathetic activity reflects, and is closely and positively correlated
with, central noradrenergic (NA) neural transmission, which is ruled by
the locus coeruleus (LC) or A6-NA-neuronal pontine group (Bamshad,
Kay Song et al., 1999; Elam, Thoren et al., 1986; Esler, Wallin et al.,
1991; Lake, Ziegler et al., 1976; Lambert, Kaye et al., 1998; Thompson
Wallin et al., 1998; Ziegler, Lake et al., 1977).
During normal basal conditions, adrenal glands supply some 20%
to the circulating pool of plasma NA, as expressed by the NA/Ad ratio 
5 (Lechin, van der Dijs et al., 1985a, 1985b, 1990a, 1990b, 1995a,
1995b, 1996a, 1996b, 1996c, 1996e). Thus, increases or decreases of this
NA/Ad ratio parallel enhancement or reduction of the contribution by
noradrenergic neural transmission to the global sympathetic activity.
According to the above, the neuropharmacological strategy we outlined
in order to enhance central NA and peripheral neural sympathetic
activities was based on three types of central acting drugs: 1) amino acid
precursors of NA (Musgrave, Bachmann et al., 1985; Musso, Brenci et
al., 1997); 2) drugs which are able to trigger enhancement of the LC-NA
neuronal firing as, for instance, alpha2 antagonists (Rodriguez-Manso,
1999; Verwaerde, Tran et al., 1997; Yan, Jobe et al., 1993), and drugs
like buspirone that trigger the firing of NA neurons and, in addition,
inhibit serotonergic (5-HT) neurons and disinhibit NA neurons from
5HT-bridling axons (Lechin, van der Dijs et al., 1997b, 1998a; Piercey,
Smith et al., 1994); 3) drugs which are able to inhibit the re-uptake of
NA by axon terminals and thus prolong the action of NA at the synaptic
level (desipramine, protryptiline, nortryptiline, doxepin) (Esler, Wallin et
al., 1991; Lechin, van der Dijs et al., 1979b; Sugrue, 1983; Yan, Jobe et
335
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
al., 1993). Finally, during the last 6 months we frequently prescribed
adrafinil or modafinil (alpha-1 agonists) which are very useful
substitutes for NA (Anderson and Harvey, 1988; Binder and Powers,
1999; Brustein and Rossignol, 1999; Duteil Rambert et al., 1990; Gerin
and Privat, 1998; Jabre and Salzsieder, 1999; Fishman, Feigembaum et
al., 1983; Sokoloff, Siegel et al., 1999; Wada, Hasegawa et al., 1997)
particularly in some cases where central NA neurons are diminished
because of aging. It is very widely known that LC-NA neurons diminish
with aging (Arranz, Blennow et al., 1996) and so elder patients may have
a limited response capacity to stimulating drugs.
Although other pharmacological manipulations would include
drugs that reduce free serotonin in the plasma (f-5HT) like tianeptine,
(Lechin, van der Dijs et al., 1998b; 1998c) the results obtained with this
tool are not presented in this report. In effect, f-5HT has been shown to
block muscular ACh-receptors and so it should play some etiopathogenic
role in MG disease, not only by suppressing Th-1 immunity but also by
interfering with neuromuscular transmission (Grassi, 1999).
Patients and Methods
Patients
The protocol used in this study was approved by the Ethical
Committee of Funda-IME) (Fundación de apoyo al Instituto de Medicina
Experimental), Universidad Central de Venezuela, Caracas, Venezuela.
All patients signed an informed consent. This was an open study carried
out on MG patients recruited from subjects arising from neurology
departments in hospitals in Venezuela and other countries. All these
patients were referred to our institute because they either did not obtain
significant improvement or show progressive impairment. Up to the
present, we have enrolled 61 MG patients. However, in this study we
included 52 patients only. The remaining nine patients started our
therapeutic trial but did not follow it for various reasons: two because of
emergency hospitalization early in the trial; five out-of-town patients
because of financial difficulties (due to travel expenses despite the fact
that our trial, blood tests and drugs were free of charge); and two patients
who only attended our institute once. Six patients had received prior
treatment in other countries (Columbia Presbyterian Hospital in New
York, Jackson Memorial Hospital in Miami, John's Hopkins Hospital in
Baltimore, Posbus Hospital in the Republic of South Africa, Mexico City
Hospital and the San José Hospital in Costa Rica). Forty-six patients
336
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
were diagnosed and previously treated in Venezuela: Hospital
Universitario in Caracas (24), Hospital Vargas in Caracas (4), Hospital
Ruiz y Paez in Ciudad Bolivar (7), Hospital Central in Valencia (4),
Hospital Universitario in Maracaibo (2), Hospital Guerra Méndez in
Valencia (2), Hospital Militar in Caracas (3).
All patients were diagnosed according to clinical features,
electromyography findings and edrophonium testing. Data referring to
clinical features are shown in Tables I to V.
Methods
Neurochemical Investigation
Plasma neurotransmitters were dosified during basal (supineresting) condition and after several stress tests: orthostasis, exercise
(Lechin, van der Dijs et al. 1995a, 1995b, 1996b, 1996d, 1996e, 1997c),
oral glucose (Lechin, van der Dijs et al., 1991, 1992, 1993), and
buspirone (Lechin, van der Dijs et al., 1997b, 1998a) according to
procedures explained in previously published papers. Blood samples for
immunological investigations were processed and transferred to
Laboratorios BIOCELL 220, C.A (Caracas, Venezuela) and for some
special tests to SPECIALTY LABORATORIES, (Michigan Av., Santa
Monica, CA, USA). These routine investigations included: antinuclear
antibodies (ANA), cellular immune dysfunction evaluation, CFIDS,
AH5O, CH5O, dsDNA autoantibodies, F-actin autoantibodies, humoral
immune evaluation, NK cell evaluation, platelet auto-antibodies, Scl-70
autoantibodies, AChR autoantibodies, striational autoantibodies, anti-JO1, C3/C4, and lymphocyte subpopulations (CD3, CD4, CD5, CD8,
CD19, CD2O, CD45RA, CD45RO), immune-globulins (IgA, IgG, IgM,
IgE).
Clinical Assessment
We modified the MG scoring system by Osserman and Genkins,
(1966) by inverting average muscle scoring (AMS) (Mantegazza Antozzi
et al., 1988; Mendell and Florence, 1990) which provided the numerical
score for muscular strength (ocular, facial, abdominal and extremity
muscles), and chewing, swallowing, phonation and respiration.
Electromyographical parameters plus clinical ratings are expressed
together. Scores were verified fortnightly and graded in percentages.
337
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Neurophamacological Therapy
Restoration of central and peripheral NA (alpha-adrenergic) activity:
a) Aminoacid precursors (L-phenylalanine, L-tyrosine), 50 mg before
breakfast.
b) Inhibitor of NA re-uptake (desipramine), 25 mg before breakfast.
c) NA-releasing agent + suppressor of serotonergic activity (buspirone)
l0-20 mg at 10 am + beta-adrenergic blocking agent (propranolol
10-20 mg).
d) Alpha-1 agonists: adrafinil (150-300 mg) or modafinil (100-200 mg)
at 10 a.m.
Because this noradrenergic (alpha-adrenergic) activation usually
induces insomnia, the treatment was not administered in afternoon hours.
When this side effect was observed, a small dose of 5hydroxytryptophan (25 mg) was administered before supper, in order to
counterbalance excessive hyper-noradrenergic induced activity. Fivehydroxytryptophan, a serotonin precursor, can be added to a small dose
(15 mg) of mirtazapine (Remeron), administered before bed. This drug
stimulates the release from central neuronal circuits of NA and 5HT,
neurotransmitters both needed to facilitate a normal slow wave sleep
(SWS). All benzodiazepines and/or gaba-mimetic drugs were banned
because they provoke strong suppression of noradrenaline + dopamine
(DA) + serotonin release (Lechin, van der Dijs et al., 1994).
Considering that late-onset MG and thymoma patients show
antibodies to striated muscle antigens (Aarli, 1999), a condition
frequently leading to muscular atrophy, we administered growth
hormone (4 IU weekly) to some of these patients in order to provoke
muscle fiber regeneration (Daugaard, Laustsen et al., 1998). This
additional therapeutic tool proved be highly effective in two cases.
Taking into account that f-5HT blocks the fetal more potently
than the adult muscle acetylcholine receptor (Grassi, 1999), we
administered small doses of tianeptine (a serotonin enhancer of platelet
uptake - 6.75 mg each other day) (Lechin, van der Dijs et al., 1998b;
1998c).
Analytical Methods
Platelet aggregation was determined at 0 min and 5 min only,
employing the adenosine diphosphate method described by Born (1962).
338
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
For plasma NA, Ad, DA, and 5HT (p-5HT + f-5HT) readers are
referred to papers previously published by our research group. These
references give details dealing with orthostasis, exercise, (Lechin, van
der Dijs et al., 1995a, 1995b, 1996e), oral glucose (Lechin, van der Dijs
et al., 1992, 1993) and buspirone (Lechin, van der Dijs et al., 1997b,
1998a) stress tests.
Results
Assessment of the therapeutic effects resulting from our
neuropharmacological approach should properly be based on clinical,
EMG and immunological parameters. However, we will also comment
on some neurochemical and neuroautonomic induced effects (see Tables
I to V).
Clinical Findings:
All MG patients showed a highly significant and sustained
reduction of symptoms during acute ( 6 days) and late (weeks and
months) periods after starting the neuropharmacological therapy. Patients
registered no relapses, no MG crises, nor new plasmapheresis after
initiation of our treatment. Immunosuppressant drugs were totally
eliminated. Suppression of steroids was acomplished progressively.
Mestinon was also progressively omitted attaining until reaching
complete or highly significant reduction. The total suppression of
Mestinon was effected in all non-thymectomized patients and in three
thymectomized cases. In the other thymectomized patients, Mestinon
was reduced to a minimum.
Immunological Findings
Increased CD5+B self-reactive and CD8 (suppressor)
lymphocytes were registered in all patients. They also showed
immunological abnormalities consistent with the Th-2 profile (increased
NK-cells, decreased NK-cell cytotoxicity, increased IgG and/or IgM
plasma levels), increased CD45RO (memory T cells). These
immunological abnormalities disappeared in all non-thymectomized
patients after sustained neuropharmacological treatment ( 3 months).
Thymectomized patients and some who had received prolonged
immunotherapy presented an atypical profile of the immune disorder (see
Tables IV and V). Most such abnormalities did not disappear despite the
significant and sustained clinical improvement shown by these patients.
339
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
TABLE I. Clinical characteristics and therapeutical responses to neuropharmacological-induced noradrenergic stimulation in 52 Myasthenia Gravis patients (Cases 1
to 17).
Patient
Since
M/Y
Nr
Osserman
Class.
Crisis
Thymectomy
Mestinon mg/d
Plasmapher.
Improv. %
Pre
Acute
Date
Sex
Age
Pre
Post
Pre
Post
1.
M
71
11/96
II-a
0
0
no
0
0
0
0
100
100
2.
F
58
07/90
II-b
3
0
no
360
0
3
0
100
80
3.
F
65
08/91
II-b
4
0
no
420
0
6
0
80
90
4.
F
36
09/93
II-a
0
0
1995
180
0
0
0
100
100
5.
F
66
06/97
II-a
0
0
no
180
0
0
0
100
100
6.
M
63
08/89
II-a
0
0
no
240
0
0
0
100
100
7.
M
61
05/97
II-b
1
0
no
240
0
1
0
100
100
8.
M
70
01/95
II-a
0
0
no
180
0
0
0
100
100
9.
F
50
05/91
II-a
0
0
1992
180
60
0
0
80
80
10.
F
35
05/93
II-b
1
0
1995
180
0
4
0
100
100
11.
F
41
02/94
I
0
0
no
60
0
0
0
100
100
12.
M
31
07/87
IV
13
0
1989
240
60
15
0
70
50
13.
M
13
04/96
II-a
0
0
no
0
0
0
0
80
80
14.
F
53
06/92
II-b
3
0
1994
360
60
6
0
60
60
15.
F
50
10/93
III
0
0
1994
180
0
2
0
100
80
16.
F
32
07/69
III
2
0
1992
240
0
0
0
100
70
17.
F
31
01/84
II-b
3
0
1984
600
0
7
0
100
80
Mestinon doses: pre = at the first visit; post = after late improvement.
Improvement: acute = at the second visit (15-day); late = > 3-month. No relapse was observed in any case.
340
Post
Late
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
TABLE II. Clinical characteristics and therapeutical responses to neuropharmacological-induced\
noradrenergic stimulation in 52 Myasthenia Gravis patients (Cases 18 to 34).
Patient
Since
M/Y
Nr
Sex
Age
18.
F
20
03/79
19.
M
27
20.
F
21.
Osserman
Class.
Crisis
Thymectomy
Mestinon mg/d
Plasmapher.
Improv. %
Date
Pre
Post
Pre
Post
Pre
IV
24
0
1980
300
0
22
0
90
90
05/98
II-a
0
0
no
210
0
0
0
100
100
18
11/96
I
0
0
no
0
0
0
0
100
100
M
38
03/95
II-a
0
0
1993
180
0
0
0
100
70
22.
F
39
02/86
I
0
0
no
240
0
0
0
100
100
23.
F
18
03/99
II-b
0
0
no
180
0
0
0
100
100
24.
F
27
10/94
IV
14
0
1996
360
120
5
0
70
70
25.
F
56
09/99
II-b
2
0
1990
240
0
4
0
100
80
26.
F
62
07/81
II-b
1
0
no
480
0
0
0
80
100
27.
F
44
10/85
II-b
0
0
no
1020
240
0
0
50
90
28.
F
32
02/92
II-a
0
0
no
180
60
0
0
70
70
29.
F
64
08/75
II-a
0
0
1976
0
0
0
0
80
80
30.
F
40
07/83
II-b
1
0
no
240
120
2
0
60
60
31.
F
32
09/94
III
12
0
1995
360
180
12
0
80
80
32.
F
16
06/97
II-b
0
0
no
360
0
0
0
100
100
33.
F
36
06/79
III
15
0
1979
300
0
18
0
70
50
34.
M
21
04/94
III
6
1
1995
360
120
3
0
40
80
Mestinon doses: pre = at the first visit; post = after late improvement.
Improvement: acute = at the second visit (15-day); late = > 3-month. No relapse was observed in any case.
341
Post
Acute
Late
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
TABLE III. Clinical characteristics and therapeutical responses to neuropharmacological-induced noradrenergic stimulation
in 52 Myasthenia Gravis patients (Cases 35 to 52).
Patient
Since
M/Y
Osserman
Class.
Crisis
Thymectomy
Mestinon\mg/d
Plasmapher.
Improv. %
Pre
Acute
Date
Nr
Sex
Age
Pre
Post
Pre
Post
35.
F
24
03/96
II-a
1
0
1997
480
0
2
0
100
80
36.
F
50
04/71
III
12
0
1993
1260
630
19
0
50
50
37.
M
36
04/98
IV
4
0
no
600
300
4
0
70
50
38.
F
46
03/93
II-a
1
0
1999
360
120
0
0
80
80
39.
F
15
03/94
II-b
0
0
1994
0
0
0
0
100
90
40.
F
51
07/74
II-a
8
0
1995
720
120
0
0
80
70
41.
F
41
04/83
II-a
1
0
no
240
60
0
0
80
80
42.
F
35
06/86
II-b
0
0
1988
480
120
0
0
90
70
43.
F
36
09/98
III
1
0
1999
360
0
1
0
100
80
44.
M
47
07/97
II-a
2
0
no
120
0
10
0
70
80
45.
F
44
02/92
II-b
0
0
1992
360
90
3
0
80
90
46.
F
36
03/98
II-a
1
0
no
480
90
1
0
70
80
47.
M
76
10/91
II-b
2
0
no
240
0
1
0
80
100
48.
F
59
04/96
II-b
0
0
no
360
120
0
0
80
80
49.
M
62
06/89
II-b
0
0
1993
240
0
0
0
70
70
50.
M
64
11/97
II-a
1
0
no
240
0
1
0
90
100
51.
M
65
04/95
II-a
0
0
no
240
120
0
0
90
90
52.
M
48
08/97
II-a
3
0
1998
300
60
2
0
80
70
Mestinon doses: pre = at the first visit; post = after late improvement.
Improvement: acute = at the second visit (15-day); late = > 3-month. No relapse was observed in any case.
342
Post
Late
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
TABLE IV. Electromyographic, neurochemical, serological and immunological parameters registered before (B) and after (A) (acute or late)
neuropharmacologically-induced improvement in 52 thymectomized* and non-thymectomized Myasthenia Gravis patients (Cases 1 to 26).
Immunological Findings
Patient
Nr
EMG
%
1
2
3
4*
5
6
7
8
9*
10*
11
12*
13
14*
15*
16*
17*
18*
19
20
21
22
23
24*
25*
26
100
80
80
80
100
100
100
100
80
70
100
50
80
60
80
70
80
90
100
100
70
100
100
70
80
100
B
0.7
0.6
0.7
1.3
0.8
1.2
0.9
1.0
0.8
0.9
1.3
0.9
0.4
0.7
0.9
1.1
0.8
1.5
0.8
1.1
0.8
1.7
0.9
1.3
0.8
1.3
NA/Ad
ratio
A
7.9
5.8
5.6
6.4
5.9
8.7
7.5
15.3
7.4
6.4
7.7
6.8
6.8
5.3
6.6
6.4
5.8
7.6
5.9
6.8
5.5
6.4
5.8
7.4
6.3
7.2
AChR/Ab
nmol/L
B
6.9
8.5
1.7
12.4
9.6
34.3
18.7
7.6
7.2
8.8
4.5
5.2
25.2
32.7
13.2
18.9
9.4
4.5
15.2
6.9
14.3
9.5
4.7
14.7
31.7
9.5
A
1.2
0.8
1.2
5.3
3.2
8.8
0.4
7.6
8.1
9.3
1.7
4.8
17.4
30.7
9.7
10.1
6.3
2.2
6.6
0.8
10.0
2.2
2.1
16.7
26.8
2.2
NK %
activity
B
18.7
15.5
22.4
15.6
21.1
20.1
19.3
22.5
24.7
26.6
22.5
27.5
19.5
23.7
25.0
21.4
18.9
23.3
18.8
21.1
19.7
25.7
21.2
17.9
25.6
21.1
CD8(s) %
A
32.4
27.7
31.6
28.4
32.6
32.7
30.4
32.7
29.7
27.8
35.5
29.9
34.7
28.9
29.9
28.2
23.8
29.0
36.1
34.8
26.4
34.1
34.7
26.8
30.0
29.7
B
47.1
43.2
39.8
31.4
44.7
45.3
41.0
39.7
35.3
37.4
49.6
46.7
43.2
39.4
38.7
41.4
39.7
40.0
48.1
55.9
59.3
46.3
40.0
47.8
43.6
39.7
A
26.2
29.6
30.4
33.6
28.4
30.0
25.2
26.3
37.4
30.0
25.8
36.4
25.2
40.1
36.0
33.3
35.6
31.8
29.7
31.7
45.8
33.8
32.7
39.6
35.7
30.2
CD5+B %
B
55.3
57.4
48.7
33.9
56.3
59.1
58.3
51.3
39.7
36.3
58.7
50.7
57.3
45.5
41.1
43.6
48,6
49,3
43,8
49,8
53.5
50.4
47.7
41.9
44.4
43.7
A
22.1
27.3
32.5
29.4
24.2
26.3
27.2
26.2
31.5
24.2
23.3
49.8
21.1
38.7
34.8
32.2
37.8
36.6
29.7
27.7
45.2
31.3
34.0
35.8
36.8
30.1
IgG (mg/dl)
B
2321
1924
2006
777
948
1018
888
1037
932
947
1055
887
1998
1777
998
886
1002
976
1489
885
1002
948
936
889
1230
966
A
1055
1133
1146
961
973
711
642
954
847
718
546
795
1000
1200
743
654
954
759
678
533
995
523
670
579
997
668
IgM (mg/dl)
B
204
117
99
185
337
549
425
399
351
269
348
366
209
297
156
229
195
201
327
289
314
270
159
223
246
223
A
75
86
87
118
217
220
212
146
347
217
222
279
147
181
148
114
137
185
89
96
253
114
58
146
200
146
EMG% = percentage of improvement (decrement + jitter); NA = noradrenaline; Ad = adrenaline; CD8(s)% = CD8 suppressor cells, percentage of
total CD3 lymphocytes; CD5+B% = percentage of total B lymphocytes; NK% activity against K563 target cells.
343
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
TABLE V. Electromyographic, neurochemical, serological and immunological parameters registered before (B) and after (A) (acute or late)
neuropharmacologically-induced improvement in 52 thymectomized* and non-thymectomized myasthenia gravis patients (Cases 27 to 52).
Patient
Nr
27
28
29*
30
31*
32
33*
34*
35*
36*
37
38*
39*
40*
41
42*
43*
44
45*
46
47
48
49*
50
51
52*
EMG
%
90
70
80
60
80
100
50
80
80
50
50
80
90
70
80
70
80
90
90
80
100
80
70
100
90
70
NA/Ad
ratio
B
A
0.7
6.8
1.5
6.6
1.7
6.7
0.8
5.9
1.1
6.8
1.4
7.7
0.9
6.3
1.1
5.8
0.9
6.6
1.5
5.7
0.8
6.5
1.1
7.7
0.9
6.5
1.0
7.6
0.9
6.3
1.3
7.1
0.7
6.4
0.9
7.5
0.9
6.8
1.1
6.8
0.8
6.5
0.9
6.3
1.1
5.8
0.9
7.3
1.3
6.2
1.2
5.9
AChR/Ab
nmol/L
B
A
8.5
1.4
0.8
0.8
3.3
2.9
4.7
5.7
2.8
1.4
4.5
0.8
15.5
18.7
9.7
6.6
4.7
1.7
13.2
9.7
34.7
29.9
26.6
14.3
9.2
4.9
0.8
0.8
0.7
0.7
0.8
0.8
13.2
5.4
7.4
1.5
3.4
1.0
12.2
6.4
10.5
2.3
14.5
5.3
10.7
13.4
2.3
0.8
0.7
0.7
13.4
12.7
NK %
activity
B
25.5
30.8
22.7
20.0
25.3
22.1
20.0
21.3
23.3
21.0
19.3
20.1
23.8
22.7
26.8
20.1
23.1
21.5
21.2
23.5
20.8
21.7
22.0
19.6
20.0
21.3
A
32.7
29.7
29.6
24.4
34.6
31.4
30.1
32.4
30.0
25.2
22.4
26.4
32.3
31.1
35.1
30.2
33.7
30.4
32.3
33.7
31.2
30.6
29.7
32.5
30.5
33.5
Immunological
Findings
CD8(s) %
CD5+B %
B
38.4
42.5
43.7
48.7
43.5
46.7
49.3
44.7
43.7
49.7
48.7
50.5
54.7
46.4
39.7
43.6
44.9
41.7
43.8
40.1
46.4
45.9
43.4
43.4
53.2
46.5
A
29.7
38.7
31.2
43.7
34.7
30.0
47.2
32.0
35.1
41.1
45.4
40.4
36.7
32.8
31.4
37.7
35.6
33.3
32.7
33.6
31.5
33.7
32.8
31.7
33.8
32.6
B
40.8
35.2
46.5
49.0
41.8
49.6
46.7
41.9
40.9
38.6
42.7
46.8
45.9
44.0
40.6
39.8
38.7
39.7
44.4
47.9
48.8
43.7
41.7
42.7
56.8
48.7
A
31.6
30.0
33.0
36.7
37.5
31.2
44.4
30.0
33.6
35.7
40.1
30.7
32.7
33.7
30.9
33.7
30.1
30.0
32.0
36.2
31.3
32.0
35.9
30.7
31.1
45.7
IgG (mg/dl)
B
895
1089
976
897
995
897
932
897
914
985
879
999
874
895
963
888
943
899
923
897
954
897
768
943
879
997
A
534
876
579
767
689
678
956
534
637
764
766
657
623
768
567
652
789
567
766
653
763
675
563
567
654
898
IgM (mg/dl)
B
179
227
234
268
170
212
214
187
212
233
225
198
201
234
199
201
199
201
214
198
200
233
195
186
200
234
A
98
159
178
176
154
153
210
155
176
214
215
179
177
198
146
177
163
144
167
179
167
156
149
194
178
248
EMG% = percentage of improvement (decrement + jitter); NA = noradrenaline; Ad = adrenaline; CD8(s)% = CD8 suppressor cells, percentage of
total CD3 lymphocytes; CD5+B% = percentage of total B lymphocytes; NK% activity against K563 target cells.
344
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Moreover, the thymectomized and immunosuppressed patients
registered a lower recovery than that shown by the non-thymectomized
or non-immunosuppressed patients.
Twenty-four out of the 27 non-thymectomized patients showed
increased levels of ACh-receptor autoantibodies before neuropharmacological treatment. After therapy, 20 of those 24 patients showed
normalization or a great reduction of this parameter. On the other hand,
an erratic response was observed in MG patients previously submitted to
surgical or drug-induced immunosuppression.
Seven out of the 25 thymectomized patients showed Scl-70 autoantibodies [usually registered in systemic lupus erythematous (SLE)
patients]. Only one patient showed increased anti-striated muscle
autoantibodies plus increased levels of ACh-R autoantibodies, before
and after therapy. He was a 38-year-old male whose myasthenia gravis
symptoms began in 1985. He was affected by hepatitis during childhood.
He was rated as a II-a MG patient. The electromyography test was
positive for MG. Thymectomized on Sept. 20, 1993, he was prescribed
Mestinon therapy which he took for six years. He accepted neither
steroids nor immunosuppressant drugs. We performed immunological
investigations on March 3/99, May 18/99, and June 22/99 with similar
immune abnormalities (reduced CD4/CD8 ratio plus increased T virgin
cells). These abnormalities were found on all three occasions. Neither
immunological nor serological abnormalities disappeared despite his
clinical improvement with neuropharmaco-logical therapy.
Neuropharmacological, neurochemical and autonomic test results
were normalized in all patients after completing our therapy. These tests
paralleled clinical improvement.
Neurochemical Findings
All patients showed very low NA/Ad ratio plus high f-5HT
plasma levels before treatment. After treatment, all neurochemical
abnormalities were reverted (see Tables IV and V). The NA/Ad plasma
ratio reached normal or greater than normal values ( 5). This NA/Ad
ratio showed further increases after orthostasis, exercise, oral glucose
and/or buspirone challenge. Noradrenaline but not adrenaline increased
during these tests. The abnormal diastolic blood pressure (DBP) and
heart rate (HR) responses returned to normal after one month of
neuropharmacological therapy. Normalization of these autonomic
parameters depends on the disappearance of adrenal gland
345
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
hyperresponsiveness + recovery of central sympathetic (neural) activity
(Lechin, van der Dijs et al., 1995a, 1995b, 1996e).
Discussion
The results obtained from the present study ratified findings
showing that myasthenia gravis is an immunologic disorder presenting a
Th-2 profile of immunity (Jaretzki, 1997; Karussis, Lehmann et al.,
1994; Kouassi, Li et al., 1990; Mokhtarian, Shirazian et al., 1993;
Ragheb and Lissak, 1993; Talal, Dauphinee et al., 1998; Yi and Lefvert,
1993; Zhang, Yu et al., 1997). The results also confirmed that
thymectomy is followed by an undefined disturbance of the immune
system (Gerli, Paganelli et al., 1999). This finding has been
demonstrated by many researchers who reported that a high percentage
of thymectomized patients developed any of several types of
autoimmune diseases, frequently systemic lupus erythematous (SLE)
(Jaretzki, 1997; Karussis, Lehmann et al., 1994; Talal, Dauphinee et al.,
1998; Yi and Lefvert, 1993; Zhang, Yu et al., 1997). Finally, the present
study showed that MG patients present a deficiency of central and
peripheral noradrenergic (NA) activity and that neuropharmacological
manipulations addressed to enhancing neural transmission of this system
are able to attain clinical remission as well as reversion of the Th-1 < Th2 imbalance (Nicholson and Kuchroo, 1996).
Our results showed that although the onset of clinical
improvement occurred rapidly (< one week), immunological
normalization took months (2-3 months). When this stage of late
improvement was obtained, doses of drugs were reduced. With regard to
this, we observed that MG patients taking high Mestinon doses
responded slowly to our neuropharmacological therapy. This finding
may be associated with the fact that acetylcholinesterase inhibitors
provoke down-regulation of ACh-receptors (Tiedt, Albuquerque et al.,
1978). We also found that MG patients taking Mestinon at night
responded more slowly than those taking only diurnal Mestinon. We
inferred that these patients do not sleep well because of a lack of
muscular relaxation induced by the sustained enhanced neuromuscular
nocturnal ACh-activity. This factor would contribute to aggravating the
diurnal muscular fatigue they usually presented. Furthermore,
considering that normalization of immunity as well as central
noradrenergic activity occurs during sleep, mainly during phases III and
IV of slow wave sleep (SWS) when growth hormone secretion peaks, it
346
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
becomes clear why normalization of the sleep pattern is necessary to the
recovery of all autoimmune diseases (Kelley, 1989).
It has long been known that NA facilitates neuromuscular
transmission and muscle contraction (Binder and Powers, 1999; Brustein
and Rossignol, 1999; Bukcharaeva, Kim et al., 1999; Duteil, Rambert et
al., 1990; Fishman, Feigembaum et al., 1983; Gerin and Privat, 1998;
Jabre and Salzsieder, 1999; Kernell, Bakels et al., 1999; Sokoloff, Siegel
et al., 1999; Sugrue, 1983). The sudden (acute) clinical improvement
registered in all our MG patients during neuropharmacological therapy
should be attributed to the effect of NA released at spinal motoneuron
levels. At this level, NA excites alpha-1 post-synaptic receptors which
facilitate muscular activity. As is amplied known, the CNS controls
posture and movements through the activation of spinal motoneurons
which receive noradrenergic excitatory and serotonergic modulatory
axons from medullary and pontine nuclei. Spinal motoneurons receive
thousands of presynaptic excitatory (NA) and inhibitory (5HT) axons
which distribute throughout their dendritic trees. Noradrenaline excites
alpha-1 receptors whereas serotonin, acting at 5HT-1a receptors,
modulates NA effects at the spinal motoneurons level. In addition, NA
synchronizes the evoked quantal release at neuromuscular junctions
(Bukcharaeva, Kim et al., 1999). Noradrenergic axons innervating spinal
motoneurons arise from the locus coeruleus (LC) also called A6-NA and
A5-NA cell groups (Lechin, van der Dijs et al., 1989). Serotonergic
axons innervating spinal motoneurons arise from the medullary raphe
pallidus and raphe obscurus nuclei.
Alpha-2 antagonist drugs excite motoneurons by increasing the
firing activity of NA neurons which release noradrenaline from axons
innervating spinal motoneurons. Similar effects are displayed by
buspirone. This drug at low doses (similar to those employed in anxiety
patients) may exert a dual effect on spinal motoneurons: an excitatory
effect by increasing the release of NA from noradrenergic axons, and an
indirect polysynaptic effect secondary to the reduction of activity of the
medullary raphe nuclei which possess 5HT-1a inhibitory autoreceptors
(Lechin, van der Dijs et al., 1979a). The short-lived effect of the alpha2
antagonists-induced release of noradrenaline can be prolonged by the
addition of an inhibitor of NA re-uptake at synaptic level (desipramine,
nortryptiline, protryptiline, doxepin, etc.) (Lechin et al., 1979b).
According to all the above, it becomes clear why neuropharmacological
therapy addressed to enhancing central NA neural transmission triggers
347
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
an acute and sudden improvement of muscular strength in MG patients.
This phenomenon has been known since the 1980s decade to
neurophysiologists familiar with the findings obtained in spinal cats.
Adrafinil and modafinil (two alpha1 agonists) trigger acetylcholine
release from motor nerves and facilitate neuromuscular transmission by a
selective action at presynpatic alpha1 receptors located at that level
(Wessler, 1992).
The late and sustained improvement registered in our study
would reflect the role played by the excitatory effect of noradrenergic
innervation at lymphoid organs and the immunosuppressant effects
displayed by plasma serotonin (f-5HT). Scientific literature dealing with
these two immunomodulating factors is too extensive to be covered in
this discussion. By way of example, however, we will cite some studies:
Ackerman, Felten et al., 1987; Bencsics, Sershen et al., 1997;
Besedowsky, del Rey et al., 1979; Felten and Olschowka, 1987; Felten,
Felten et al., 1987; Livnat, Felten et al., 1985; Lorton, Hewitt et al.,
1990; Tang, Shankar et al., 1999; Thyaga-Rajan, Madden et al., 1999.
It has been exhaustively demonstrated that the regions in which
lymphocytes T cells reside, and through which they recirculate, receive
direct sympathetic neural input. Therefore, the immune system can be
considered “hard-wired” to the brain. Chemical sympathectomy of adult
mice resulted in reduced antibody responses to T-dependent antigens.
The interaction between sympathetic NA nerve fibers and cells of the
immune system has been shown through the distribution of tyrosine
hydrolase (TH+) nerve fibers among lymphocytes and macrophages in
lymphoid organs, the expression of adrenoceptors on cells of the immune
system, and the immunomodulatory effects of NA. In old rats, a
conspicuous decline in NA innervation and NA contents is observed in
the splenic white pulp as well as in the cell bodies in superior celiacmesenteric ganglia that provide preganglionic sympathetic innervation to
the spleen (Arnason, 1993; Carlson, Fox et al., 1997; Madden. Felten et
al., 1994a; Roszman and Carlson, 1991). Paralleling these alterations in
sympathetic NA neuronal activity is an age-related loss of T cell
mediated immune responses, including reduced T cell proliferation and
IL-2 production by antigen- and mitogen-stimulated lymphocytes.
Treatment of these rats with drugs inducing noradrenergic regeneration
and re-innervation reverted the rats’ immune abnormalities (Tang,
Shankar et al., 1999; Thyaga-Rajan, Madden et al., 1999). Noradrenergic
innervation of the spleen is responsible for a significant increase of
348
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
gamma-interferon, IL-2 and tumor necrosis factor alpha, the three Th-1
cytokines, and a lowering of IL-4, IL-5 and IL-10 (TH-2 cytokines)
production (Carlson, Fox et al., 1997; Madden, Moynihan et al., 1994b;
Spengler, Allen et al., 1990). Other evidence showed that elevated
plasma NA concentrations increased the level of Th-1 cytokines (Kappel,
Poulsen et al., 1998; Ross, Williams et al., 1987). These and other
findings demonstrate that the noradrenergic innervation of bone marrow
is functionally dynamic and is responsive to central activation.
Furthermore, these results lend credence to the premise that neural
mechanisms participate in regulating lymphopoietic cellular events.
Data demonstrates that adrenaline (Ad) suppresses Th-1
immunity and stimulates Th-2 cytokines (Cook-Mills, Cohen et al.,
1995; Crary, Houser et al., 1983; Cunnick, Lysle et al., 1990; Ernstrom
and Sandberg, 1973; Felsner, Hofer et al., 1995; Kouassi, Li et al., 1990;
Tvede, Kappel et al., 1994; Van Tits, Michel et al., 1990). These effects
are mediated by beta-adrenoceptors in human lymphocytes. Betaadrenoceptors also mediate NK- activity (Kappel, Tvede et al., 1991;
Schedlowski, Hosch et al., 1996; Vredevoe, Moser et al., 1995)
The role of circulating free serotonin (f-5HT) has also been
exhaustively investigated. For instance, macrophages possess a 5HTuptake system, the kinetic properties of which make them sensitive to
changes in plasma levels of 5HT (Fuchs, Campbell et al., 1988; Jackson,
Walker et al., 1998; Sternberg, Wedner et al., 1987; Young and
Matthews, 1995). In addition, it has been shown that serotonin stimulates
Th-2 lymphokine secretion (Paegelow, Werner et al., 1985). It is known
that NA alters the capacity of platelets to sequester and/or catabolize
5HT, thus regulating its physiologically active pool in the plasma (Fuchs,
Campbell et al., 1988; Walker and Codd, 1985; Warren, Kane et al.,
1990). Thus, through its ability to regulate plasma levels of 5HT, an
immunosuppressive amine with access to macrophages, the nervous
system can influence cells involved in antigen recognition. In aging
rodents and humans, the central noradrenergic deficit is associated with a
decreased platelet affinity for 5HT and an increased plasma content of
5HT. In addition to the above, the increased f-5HT we registered in our
MG patients would also be associated with the raised adrenaline plasma
levels they presented. This latter factor would be responsible for the
increased platelet aggregability we registered in all our MG patients
(Larsson, Hjemdahl et al., 1989). Finally, it has been known for several
years that pharmacological enhancement of 5HT metabolism suppresses
349
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
the immune response in vivo. This immunosuppression occurs
peripherally, not centrally (Walker and Codd, 1985).
Free serotonin in plasma should also play some important role in
triggering myasthenic crisis since we were able to accelerate the
recovery of several MG patients affected by this severe complication by
administering tianeptine to them. This finding is consistent with the
bronchial constriction effect exerted by f-5HT in asthmatic patients who
were also dramatically improved by this serotonin-enhancing uptaker
drug (Lechin, van der Dijs et al., 1996b, 1998b, 1998c).
Acknowledgments
This work was supported by grants from FundaIME and
Fundaneuroinmunologia.
References
Aarli, J.A. (1999).: Late-onset myasthenia gravis. A changing scene.
Arch. Neurol. 56: 25-27.
Ackerman, K.D., Felten, S.Y., Bellinger, D.L., Livnat, S. and Felten,
D.L. (1987).: Noradrenergic sympathetic innervation of spleen
and lymph nodes in relation to specific cellular compartments. In:
Progress in Immunology Edited by B. Cynader and R.G. Miller.
Academic Press. Orlando, FL. 4: 588-600.
Anderson, A. and Harvey, A. (1988).: Effects of the facilitatory
compounds cathecol, guanidine, noradrenaline, and phencyclidine on presynaptic currents of mouse motor nerve terminals.
Naunyn-Schmiedeberg´s Arch. Pharmacol. 338: 133-137.
Arnason, B.G.W. (1993).: The sympathetic nervous system and the
immune response. In: Clinical autonomous disorders. Evaluation
and management. Edited by P. Low. Little Brown, London. pp
143-165.
Arranz, B., Blennow, K., Ekman, R., Eriksson, A., Mansson, J-E. and
Marcusson, J. (1996).: Brain monoaminergic and neuropeptidergic variations in human aging. J. Neural Transm. 103: 101115.
Bamshad, M., Kay Song, C. and Bartnes, T.J. (1999).: CNS origins of
the sympathetic nervous system outflow to brown adipose tissue.
Am. J. Physiol. 276(Regulatory Integrative Comp Physiol 45):
R1569-R1578.
350
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Barnard, A., Mahon, B.P., Watkins, J., Redhead, K. and Mills, K.H.G.
(1996).: Th1/Th2 cell dichotomy in acquired immunity to
Bordetella Pertussis: variables in the in vivo priming and in vitro
cytokine detection techniques affect the classification of T-cell
subsets as Th1, Th2 or Th0. Immunology 87: 372-380.
Bencsics, A., Sershen, H., Baranyi, M., Hashim, A., Lajtha, H.A. and
Vizi, E.S. (1997).: Dopamine, as well as norepinephrine, is a link
between noradrenergic nerve terminals and splenocytes. Brain
Res. 761: 236-243.
Besedowsky, H.O., del Rey, A.E., Sorkin, E., Da Prada, M. and Keller,
H.H. (1979).: Immunoregulation mediated by the sympathetic
nervous system. Cell Immunol. 48: 346-355.
Binder, M.D. and Powers, R.K. (1999).: Synaptic integration in spinal
motoneurons. J. Physiol. 93: 71-79.
Born, G.V.R. (1962).: Aggregation of blood platelets by adenosine
diphosphate and its reversal. Nature 194: 927-929.
Brustein, E. and Rossignol, S. (1999).: Recovery of locomotion after
ventral and ventrolateral spinal lesions in the cat. II. Effects of
noradrenergic and serotonergic drugs. J. Neurophysiol. 81: 15131530.
Bukcharaeva, E.A., Kim, K.C., Moravec, J., Nikolsky, E.E. and
Vyskocil, F. (1999).: Noradrenaline synchronizes evoked quantal
release at frog neuromuscular junctions. J. Physiol. 517: 879-888.
Carlson, S.L., Fox, S. and Abell, K.M. (1997).: Catecholamine
modulation of lymphocyte homing to lymphoid tissues. Brain
Behav. Immun. 11: 307-320.
Cook-Mills, J.M., Cohen, R.L., Pearlman, R.L. and Chambers, D.A.
(1995).: Inhibition of lymphocytes activation by catecholamines:
Evidence for a non-classical mechanism of catecholamine action.
Immunology 5: 544-549.
Crary, B., Houser, S.L., Borysenko, M., Kutz, L., Hovan, C., Ault, K.A.,
Wayner, H.L. and Benson, H. (1983).: Decreased mitogen
responsiveness of mononuclear cells from peripheral blood after
epinephrine administration in humans. J. Immunol. 130: 694-697.
Cunnick, J.E., Lysle, D.T., Kucinski, B.J. and Rabin, B.S. (1990).:
Evidence that shock-induced immune suppression is mediated by
adrenal hormones and peripheral beta-adrenergic receptors.
Pharmacol. Biochem. Behav. 36: 645-651.
351
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Daugaard, J.R., Laustsen, L., Hansen, B.S. and Richter, E.A. (1998).:
Growth hormone induces muscle fiber type transformation in
growth hormone-deficient rat. Acta Physiol. Scand. 164: 119126.
Duteil, J., Rambert, F.A., Pessonnier, J., Gombert, R. and Assous E.
(1990).: Central alpha1-adrenergic stimulation in relation to the
behavior stimulating effect of modafinil; studies with
experimental animals. Eur. J. Pharmacol. 180: 49-58.
Elam, M., Thoren, P. and Svenson, T.H. (1986).: Locus coeruleus
neurons and sympathetic nerves: Activation by visceral afferents.
Brain Res. 375: 117-125.
Ernstrom, U. and Sandberg, G. (1973).: Effects of alpha- and betareceptor stimulation on the release of lymphocytes and
granulocytes from the spleen. Scand. J. Hematol. 11: 275-286.
Esler, M.D., Wallin, G., Dorward, P.K., Eisenhofer, G., Westerman, R.,
Meredith, I., Lambert, G., Cox, H.S. and Jennings, G. (1991).:
Effects of desipramine on sympathetic nerve firing and
norepinephrine spillover to plasma in humans. Amer. J. Physiol.
260: R817-R823.
Faxvaag, A., Espevik, T. and Dalen, A. (1995).: An immunosuppressive
murine leukaemia virus induces a Th-1
Th-2 switch and
abrogates the IgM antibody response to sheep erythrocytes by
suppressing the production of IL-2. Clin. Exp. Immunol. 102:
487-495.
Felsner, P., Hofer, D., Rinner, I., Porta, S., Korsatko, W. and
Schauenstein, K. (1995).: Adrenergic suppression of peripheral
blood T cell reactivity in the rat is due to activation of peripheral
alpha2-receptors. J. Neuroimmunol. 57: 27-34.
Felten, D.L., Felten, S.Y., Bellinger, D.L., Carlson, S.L., Ackerman,
K.D., Madden, K.S., Olschowky, J.A. and Livnat, S. (1987).:
Noradrenergic sympathetic neural interactions with the immune
system: Structure and function. Immunol. Rev. 100: 225-260.
Felten, S.Y. and Olschowka, J.A. (1987).: Noradrenergic sympathetic
innervation of the spleen. II. Tyrosine hydroxylase (TH)-positive
nerve terminals form synaptic-like contacts on lymphocytes in
the splenic white pulp. J. Neurosci. Res. 18: 37-48.
Fishman, R.H., Feigembaum, J.J., Yanai, J. and Klawans, H.L. (1983).:
The relative importance of dopamine and norepinephrine in
mediating locomotor activity. Prog. Neurobiol. 20: 55-88.
352
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Fuchs, B.A., Campbell, K.S. and Munson, A.E. (1988).: Norepinephrine
and serotonin content of the murine spleen: its relationship to
lymphocyte beta-adrenergic receptor density and the humoral
immune response in vivo and in vitro. Cell Immunol. 117: 339351.
Gerin, C. and Privat, A. (1998).: Direct evidence for the link between
monoaminergic descending pathways and motor activity: II. A
study with microdialysis probes implanted in the ventral horn of
the spinal cord. Brain Res. 794: 169-173.
Gerli, R., Paganelli, R., Cossarizza, A., Muscat, C., Piccolo, G., Barbieri,
D., Mariotti, S., Monti, D., Bistoni, O., Raiola, E., Venanzi, F.M.,
Bertotto, A. and Franceschi, C. (1999).: Long-term immunologic
effects of thymectomy in patients with myasthenia gravis. J.
Allergy Clin. Immunol. 103: 865-872.
Grassi, F. (1999).: 5-hydroxytryptamine blocks the fetal more potently
than the adult mouse muscle acetylcholine-receptor. Pflügers
Arch. – Eur. J. Physiol. 437: 903-909.
Jabre, J.F. and Salzsieder, B.T. (1999).: An EMG study of functional
cortico-motoneuronal connections in humans. J. Physiol. 93: 147154.
Jackson, J.C., Walker, R.F., Brooks, W.H. and Roszman, T.L. (1998).:
Specific uptake of serotonin by murine macrophages. Life Sci.
42: 1641-1650.
Jaretzki III, A. (1997).: Thymectomy for myasthenia gravis: Analysis of
the controversy regarding technique and results. Neurology
48(Suppl 5): S52-S63.
Kappel, M., Poulsen, T.D., Galbo, H. and Pedersen, D.K. (1998).:
Effects of elevated plasma noradrenaline concentration on the
immune system in humans. Eur. J. Appl. Physiol. 79: 93-98.
Kappel, M., Tvede, N., Galbo, H., Haahr, P.M., Kjaer, M., Klarlund, K.
and Pedersen, B.K. (1991).: Evidence that the effect of physical
exercise on NK cell activity is mediated by epinephrine. J. Appl.
Physiol. 70: 2530-2534.
Karussis, D.M., Lehmann, D., Brenner, T., Wirguin, I., Mizrachi, K.R.,
Sicsic, C. and Abramsky, O. (1994).: Immunomodulation of
experimental autoimmune myasthenia gravis with linomide. J.
Neuroimmunol. 55: 187-193.
Kelley, K.W. (1989).: Growth hormone, lymphocytes and macrophages.
Biochem. Pharmacol. 38: 705-713.
353
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Kernell, D., Bakels, R. and Copray, J.C.V.M. (1999).: Discharge
properties of motoneurones: How are they matched to the
properties and use of their muscle units? J. Physiol. 93: 87-96.
Kouassi, E., Li, Y.S. and Revillard, J.P. (1990).: Catecholamine
regulation of mouse B cell activation: functional dichotomy
between lps and anti-immuno-globulin antibody responses. In:
Messengers in a Neuroimmune Axis. Edited by M.S. O’Dorisio
and A. Panerai. Ann. N.Y. Acad. Sci., New York, 594: 391-392.
Lake, C.R., Ziegler, M.G. and Kopin, I.J. (1976).: Use of plasma
norepinephrine for evaluation of sympathetic neuronal function in
man. Life Sci. 18: 1315-1326.
Lambert, G.W., Kaye, D.M., Thompson, J.M., Turner, A.G., Cox, H.S.,
Vaz, M., Jennings, G.L., Wallin, B.G. and Esler, M.D. (1998).:
Internal jugular venous spillover of noradrenaline and metabolites
and their association with sympathetic nervous activity. Acta
Physiol. Scand. 163: 155-163.
Larsson, P.T., Hjemdahl, P., Olsson, G., Egberg, N. and Hornstra, G.
(1989).: Altered platelet function during mental stress and
adrenaline infusion in humans: evidence for an increased
aggregability in vivo as measured by filtragometry. Clin. Sci. 76:
369-376.
Lechin, F., van der Dijs, B. and Benaim, M. (1996a).:Stress vs
depression. (Review). Prog. Neuro-Psychopharmacol. Biol.
Psychiat. 20: 899-950.
Lechin, F., van der Dijs, B. and Lechin, M. (1996b).: Plasma neurotransmitters and functional illness. (Review) Psychother. Psychosom.
65: 293-318.
Lechin, F., van der Dijs, B. and Lechin, E. (1979a).: The Autonomic
Nervous System: Physiological basis of psychosomatic therapy.
Barcelona, Spain: Editorial Cientifico-Medica, Chapter III, pp
31-40.
Lechin, F., van der Dijs, B. and Lechin, E. (1979b).: The Autonomic
Nervous System: Physiological basis of psychosomatic therapy.
Barcelona, Spain: Editorial Cientifico-Medica, Chapter VIII, pp
119-49.
Lechin, F., van der Dijs, B., Orozco, B., Lechin, M.E. and Lechin, A.E.
(1996c).: Increased levels of free-serotonin in plasma of
symptomatic asthmatic patients. Ann. Allergy Asthma Immunol.
77: 245-253.
354
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Lechin, F., van der Dijs, B., Orozco, B., Baez, S., Rada, I., Garcia, Z.,
Jara, H., Lechin, A.E. and Lechin, M.E. (1996d).: Plasma
neurotransmitters, blood pressure and heart rate during supineresting, orthostasis and moderate exercise stress test in healthy
humans before and after parasympathetic blockade with atropine.
Res. Comm. Biol. Psychol. Psychiat. 21: 55-71.
Lechin, F., van der Dijs, B., Orozco, B., Lechin, A.E., Baez, S., Lechin,
M.E., Benaim, M., Acosta, E., Arocha, L., Jimenez, V., Leon, G.
and Garcia, Z. (1996e).: Plasma neurotransmitters, blood pressure
and heart rate during supine-resting, orthostasis and moderate
exercise in severely ill patients: a model of failing to cope with
stress. Psychother. Psychosom. 65: 129-136.
Lechin, F., van der Dijs, B., Jara, H., Baez, S., Orozco, B., Jahn, E.,
Lechin, M.E., Jimenez, V. and Lechin, A.E. (1997a).: Successful
neuropharmacological treatment of myasthenia gravis: Report of
eight cases. Res. Comm. Biol. Psychol. Psychiat. 22: 83-96.
Lechin, F., van der Dijs, B., Jara, H., Orozco, B., Baez, S., Jahn, E.,
Benaim, M., Lechin, E., Lechin, M.E., Jimenez, V. and Lechin,
A.E. (1997b).: Plasma neurotransmitter profiles of anxiety,
phobia and panic disorder patients. Acute and chronic effects of
buspirone. Res. Comm. Biol. Psychol. Psychiat. 22:113-156.
Lechin, F., van der Dijs, B., Lechin, M.E., Orozco, B., Baez, S., Lechin,
A.E., Jahn, E. and Jimenez V. (1997c).: Plasma
neurotransmitters, blood pressure and heart rate during supineresting, orthostasis, and moderate exercise conditions in two
types of hypertensive patients. Res. Comm. Biol. Psychol.
Psychiat. 22: 97-112.
Lechin, F., van der Dijs, B., Jara, H., Orozco, B., Báez, S., Benaim, M.,
Lechin, M. and Lechin, A. (1998a).: Effects of buspirone on
plasma neurotransmitters in healthy subjects. J. Neural
Transmission 105: 561-573.
Lechin, F., van der Dijs, B., Orozco, B., Jara, H., Rada, I., Lechin, M.E.
and Lechin, A.E. (1998b).: Neuropharmacological treatment of
bronchial asthma with an antidepressant drug: tianeptine. A
double-blind crossover placebo-controlled study. Clin.
Pharmacol. Ther. 64: 223-232.
Lechin, F., van der Dijs, B., Orozco, B., Jara, H., Rada, I., Lechin, M.E.
and Lechin, A.E. (1998c).: The serotonin uptake-enhancing drug
tianeptine suppresses asthmatic symptoms in children: A double-
355
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
blind, crossover, placebo-controlled study. J. Clin. Pharmacol.
38: 918-925.
Lechin, F., van der Dijs, B., Orozco, B., Lechin, M.E., Baez, S., Lechin,
A.E., Rada, I., Acosta, E., Arocha, L., Jimenez, V., Leon, G. and
Garcia, Z. (1995a).: Plasma neurotransmitters, blood pressure,
and heart rate during supine-resting, orthostasis, and moderate
exercise conditions in major depressed patients. Biol. Psychiatry
38: 166-173.
Lechin, F., van der Dijs, B., Orozco, B., Lechin, A.E., Baez. S., Lechin,
M.E., Rada, I., Acosta, E., Arocha, L., Jimenez, V., Leon, G. and
Garcia, Z. (1995b).: Plasma neurotransmitters, blood pressure,
and heart rate during supine resting, othostasis, and moderate
exercise in dysthymic depressed patients. Biol. Psychiatry 37:
884-891.
Lechin, F., van der Dijs, B., Vitelli-Flores, G., Baez, S., Lechin, M.E.,
Lechin, A.E., Orozco, B., Rada, I., Leon, G. and Jimenez, V.
(1994).: Peripheral blood immunological parameters in long-term
benzodiazepine users. Clin. Neuropharmacol. 17: 63-72.
Lechin, F., van der Dijs, B., Lechin, M.E., Jara, H., Lechin, A., Baez, S.,
Orozco, B., Rada, I., Cabrera, A., Arocha, L., Jimenez, V. and
Leon, G. (1993).: Plasma neurotransmitters throughout oral
glucose tolerance test in non-depressed essential hypertension
patients. Clin. Exper. Hypertension 15: 209-240.
Lechin, F., van der Dijs, B., Lechin, M.E., Baez, S., Jara, H., Lechin, A.,
Orozco, B., Rada, I., Cabrera, A., Jimenez, V. and Leon, G.
(1992).: Effects of an oral glucose load on plasma
neurotransmitters in humans: involvement of REM sleep?
Neuropsychobiology 26: 4-11.
Lechin, F., van der Dijs, B., Lechin, A.E., Lechin, M.E., Coll-Garcia, E.,
Jara, H., Cabrera, A., Jimenez, V., Gomez, F., Tovar, D., Rada, I.
and Arocha, L. (1991).: Doxepin therapy for postprandial
symptomatic hypoglycemic patients: neurochemical, hormonal
and metabolic disturbances. Clin. Sci. 80: 373-384.
Lechin, F., van der Dijs, B., Vitelli-Florez, G., Lechin-Báez, S., Azocar,
J., Cabrera, A., Lechin, A., Jara, H., Lechin, M., Gómez, F. and
Arocha, L. (1990a).: Psychoneuroendocrinological and
immunological parameters in cancer patients: involvement of
stress and depression. Psychoneuroendocrinology 15: 425-451.
356
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Lechin, F., van der Dijs, B., Rada, I., Jara, H., Lechin, A.E., Cabrera, A.,
Lechin, M.E., Jimenez, V., Gómez, F., Villa, S., Acosta, E. and
Arocha L. (1990b).: Plasma neurotransmitters and cortisol in
duodenal ulcer patients: role of stress. Dig. Dis. Sci, 35: 13131319.
Lechin, F., van der Dijs, B., Lechin, M., Camero, R., Lechin, A., Villa,
S. and Reinfeld, B. (1989).: Intramuscular clonidine test in
severely diseased patients. In: Neurochemistry and Clinical
Disorders: Circuitry of Some Psychiatric and Psychosomatic
Syndromes. Edited by F. Lechin and B. van der Dijs. CRC Press,
Boca Raton, FL. pp 215-226.
Lechin, F., van der Dijs, B., Jackubowicz, D., Camero, R.E., Villa, S.,
Arocha, L. and Lechin, A.E. (1985a).: Effects of clonidine on
blood pressure, noradrenaline, cortisol, growth hormone, and
prolactin plasma levels in high and low intestinal tone depressed
patients. Neuroendocrinology 41: 156-162.
Lechin, F., van der Dijs, B., Jackubowicz, D., Camero, R.E., Villa, S.,
Lechin, E. and Gomez, F. (1985b).: Effects of clonidine on blood
pressure, noradrenaline, cortisol, growth hormone, and prolactin
plasma levels in high and low intestinal tone subjects.
Neuroendocrinology 40: 253-261.
Livnat, S., Felten, S.Y., Carlson, S.L., Bellinger, D.L. and Felten, D.L.
(1985).: Involvement of peripheral and central catecholamine
systems in neural-immune interactions. J. Neuroimmunol. 10: 530.
Lorton, D., Hewitt, D., Bellinger, D.L., Felten, S.Y. and Felten, D.L.
(1990).: Noradrenergic reinnervation of the rat spleen following
chemical sympathectomy with 6-hydroxydopamine: Pattern and
time course of reinnervation. Brain Behav. Immun. 4: 198-222.
Madden, K.S., Felten, S.Y., Felten, D.L., Hardy, C.A. and Livnat, S.
(1994a).: Sympathetic nervous system modulation of the immune
system. II. Induction of lymphocyte proliferation and migration
in vivo by chemical sympathectomy. J. Neuro-immunol. 49: 6775.
Madden, K.S., Moynihan, J.A., Brenner, G.J., Felten, S.Y., Felten, D.L.
and Livnat, S. (1994b).:Sympathetic nervous system modulation
of the immune system. III. Alterations in T and B cell
proliferation and differentiation in vitro following chemical
sympathectomy. J. Neuroimmunol. 49: 77-87.
357
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Mantegazza, R., Antozzi, C., Peluchetti, D., Sghirlanzoni, A. and
Cornelio, F. (1988).: Azathioprine as a single drug or in
combination with steroids in the treatment of myasthenia gravis.
J. Neurol. 235: 449-453.
Mendell, J.R. and Florence, J. (1990).: Manual muscle testing. Muscle
Nerve 13: 516-520.
Mokhtarian, F., Shirazian, D. and Grob, D. (1993).: Production of
interferon gamma and interleukin-2 by peripheral blood
lymphocytes of patients with Myasthenia gravis and other
autoimmune diseases. In: Myasthenia Gravis and Related
Disorders: Experimental and Clinical Aspects. Edited by S.
Penn, D.P. Richman, R.L. Ruff, and V.A. Lennon. Ann. N.Y.
Acad. Sci., New York. 681: 315-318.
Musgrave, I.F., Bachmann, A.W., Jackson, R.V. and Gordon, R.D.
(1985).: Increased plasma noradrenaline during low dose
adrenaline infusion in resting man and during sympathetic
stimulation. Clin. Exp. Pharmacol. Physiol. 12: 285-289.
Musso, N.R., Brenci, S., Indiveri, F. and Lotti, G. (1997).: L-tyrosine
and nicotine induce synthesis of L-Dopa and norepinephrine in
human lymphocytes. J. Neuroimmunol. 74: 117-120.
Nicholson, L.B. and Kuchroo, V. (1996).: Manipulation of the Th1/Th2
balance in autoimmune disease. Curr. Opin. Immunol. 8: 837842.
Osserman, K.E. and Genkins, G. (1966).: Critical reappraisal of the use
of edrophonium (tensilon) chloride test in myasthenia gravis and
significance of clinical classification. N.Y.: Ann. N.Y. Acad. Sci.
135: 312-334.
Paegelow, I., Werner, H., Hagen, M., Wartner, U. and Lange, P. (1985).:
Influence of serotonin on lymphokine secretion in vitro. Int. J.
Immunopharmacol. 7: 889-896.
Piercey, M.F., Smith, M.W. and Lum-Ragan, J.T. (1994).: Excitation of
noradrenergic cell firing by 5-hydroxytryptamine 1A agonists
correlates with dopamine antagonist properties. J. Pharmacol.
Exp. Ther. 268: 1297-1303.
Ragheb, S. and Lisak, R.P. (1993).: Phenotypic and functional
abnormalities of B cells in myasthenia gravis. In: Miasthenia
Gravis and Related Disorders: Experimental and Clinical
Aspects. Edited by S. Penn, D.P. Richman, R.L. Ruff, and V.A.
Lennon. Ann. N.Y. Acad. Sci., New York. 681: 257-262.
358
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Rodríguez-Manso, G. (1999).: Yohimbine interacts with the
dopaminergic system to reverse sexual satiation: further evidence
for a role of sexual motivation in sexual exhaustion. Eur. J.
Pharmacol. 372: 1-8.
Romagnani, S. (1996).: TH1 and TH2 in human diseases. Clin. Immunol.
Immunopathol. 80: 225-235.
Ross, S.E., Williams, R.O., Mason, L.J., Mauri, C., MarinovaMutafchieva, L., Malfait, A.M., Maini, R.N. and Feldmann, M.
(1987).: Suppression of TNFalpha expression, inhibition of th1
activity, and amelioration of collagen-induced arthritis by
Rolipram. J. Immunol. 159: 6253-6259.
Roszman, T.L. and Carlson, S.L. (1991).: Neurotransmitters and
molecular signalling in the immune response. In: Psychoneuroimmunology. Edited by R. Ader, D.L. Felten and N. Cohen.
Academic Press, San Diego, pp. 311-339.
Schedlowski, M., Hosch, W., Oberbeck, R., Benschop, R.J., Jacobs, R.,
Raab, H.R. and Smidt, R.E. (1996).: Catecholamines modulate
human NK cell circulation and function via spleen-independent
beta2-adrenergic mechanisms. J. Immunol. 156: 93-99.
Sokoloff, A.J., Siegel, S.G. and Kope, T.C. (1999).: Recruitment order
among motoneurons from different motor nuclei. J.
Neurophysiol. 81: 2485-2492.
Spengler, R.N., Allen, R.M., Remick, D.G., Strieter, R.M. and Kunkel,
S.L. (1990).: Stimulation of alpha adrenergic receptor augments
the production of macrophage-derived tumor necrosis factor. J.
Immunol. 145: 1430-1434.
Sternberg, E.M., Wedner, H.J., Leung, M.K. and Parker, C.W. (1987).:
Effect of serotonin (5-HT) and other monoamine on murine
macrophages: modulation of interferon-gamma induced
phagocytosis. J. Immunol. 138(12): 4360-4365.
Sugrue, M.F. (1983).: Chronic antidepressant therapy and associated
changes in central monoaminergic receptor functioning.
Pharmacol. Ther. 21: 1-33.
Talal, N., Dauphinee, M. and Ahmed, S.A. (1998).: CD5 B cells in
autoimmunity. In: CD5 B Cells in Development and Disease.
Edited by L.A. Herzenberg, G. Haughton and K. Rajewsky. Ann.
N.Y. Acad. Sci., New York. 651: 551-562.
359
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Tang, Y., Shankar, R., Gamelli, R. and Jones, S. (1999).: Dynamic
norepinephrine alterations in bone marrow: Evidence of
functional innervation. J. Neuroimmunol. 96: 182-189.
Thompson, J.M., Wallin, B.G., Lambert, G.W., Jennings, G.L. and Esler,
M.D. (1998).: Human muscle sympathetic activity and cardiac
catecholamine spillover: No support for augmented sympathetic
noradrenaline release by adrenaline co-transmission. Clin. Sci.
94: 383-393.
Thyaga-Rajan, S., Madden, K.S., Stevens, S.Y. and Felten, D.L. (1999).:
Effects of l-deprenyl treatment on noradrenergic innervation and
immune reactivity in lymphoid organs of young F344 rats. J.
Neuroimmunol. 96: 57-65.
Tiedt, T.N., Albuquerque, E.X., Hudson, S.C. and Rash, J.E. (1978).:
Neostigmine-induced alterations at the mammalian neuromuscular junction. I. Muscle contraction and electrophysiology.
J. Pharmacol. Exp. Ther. 205: 326-339.
Tvede, N., Kappel, M., Klarlund, K., Duhn, S., Halkjaer-Kristensen, J.,
Kjaer, M., Galbo, H. and Pedersen, B.K. (1994).: Evidence that
the effect of bicycle exercise on blood mononuclear cell
proliferative responses and subsets is mediated by epinephrine.
Int. J. Sports Med. 15: 100-104.
Van Tits, L.J.H., Michel, M.C., Grosse-Wilde, H., Happel, M., Eigler,
F.W., Soliman, A. and Brodde, O.E. (1990).: Catecholamines
increase lymphocyte beta2-adrenergic receptors via a beta2adrenergic, spleen dependent process. Am. J. Physiol. 258: E191E202.
Verwaerde, P., Tran, M.A., Montastruc, J.L., Senard, J.M. (1997).:
Effects of yohimbine, an 2-adrenoceptor antagonist, on
experimental neurogenic orthostatic hypotension. Fundam. Clin.
Pharmacol. 11: 567-575.
Vredevoe, D.L., Moser, D.K., Gan, X.H. and Bonavida, B. (1995).:
Natural killer cell anergy to cytokine stimulants in a subgroup of
patients with heart failure: relationship to norepinephrine.
Neuroimmunomodulation 2: 16-24.
Wada, T., Hasegawa, Y. and Ono, H. (1997).: Characterization of alphaadrenoceptor subtypes in facilitation of rat spinal motoneuron
activity. Eur. J. Pharmacol. 340: 45-52.
360
VOL. 31, NOS. 5 & 6, 2000
JOURNAL OF MEDICINE
Walker, R.F. and Codd, E.E. (1985).: Neuroimmunomodulatory
interaction of norepinephrine and serotonin. J. Neuroimmunol.
10: 41-58.
Warren, R.P., Kane, K.K., Burger, R.A. and Singh, V.K. (1990).:
Serotonin induced suppression of lymphocyte DNA synthesis and
natural killer cell activity. In: Neuropeptides and
Immunopeptides: Messengers in a Neuroimmune Axis. Edited by
M.S. O’Dorisio and A. Panerai. Ann. N.Y. Acad. Sci., New
York. 594: 429-431.
Wessler, I. (1992).: Acetylcholine and motor nerves: storage, release,
and presynpatic modulation by autoreceptors and adrenoceptors.
Int. Rev. Neurobiol. 34: 283-373.
Yan, Q-S., Jobe, P.C. and Dailey, J.W. (1993).: Noradrenergic
mechanisms for the anticonvulsant effects of desipramine and
yohimbine in genetically epilepsy-prone rats: Studies with
microdialysis. Brain Res. 610: 24-31.
Yi, Q. and Lefvert, K. (1993).: Human muscle acetylcholine receptor
reactive T and B lymphocytes in myasthenia gravis. In:
Myasthenia Gravis and Related Disorders: Experimental and
Clinical Aspects. Edited by S. Penn, D.P. Richman, R.L. Ruff and
V.A. Lennon. Ann. N.Y. Acad. Sci., New York. 681: 339-341.
Young, M.R.I. and Matthews, J.P. (1995).: Serotonin regulation of T cell
subpopulations and of macrophage accessory function.
Immunology 84: 148-152.
Zhang, G-X., Yu, L-Y., Shi, F-D., Xiao, B-G., Björk, J., Hedlund, G. and
Link, H. (1997).: Linomide suppresses both Th1 and Th2
cytokines in experimental autoimmune myasthenia gravis. J.
Neuroimmunol. 73: 175-182.
Ziegler, M.G., Lake, C.R. and Wood, J.H. (1977).: Relationship between
norepinephrine in blood and cerebrospinal fluid in the presence of
a blood cerebrospinal fluid barrier for norepinephrine. J.
Neurochem. 28: 677-679.
361