Serum 25-hydroxy vitamin D, vitamin B12 and folic acid levels in myasthenic crisis

Year 2022, Volume: 4 Issue: 1, 29 - 33, 24.01.2022

Recep Yevgi , Caner Baydar

https://doi.org/10.38053/acmj.1009428

Abstract

Aim: Myasthenia gravis (MG) is an autoimmune disease often caused by autoantibodies against postsynaptic acetylcholine receptors (AChR). It is known that vitamin D (VD), vitamin B12 and folic acid have some effects on the immune system. The aim of this study is to evaluate whether there is a difference in serum VD, vitamin B12 and folic acid levels in MG patients during the myasthenic crisis period compared to the non-crisis period.
Material and Method: 32 patients followed up with the diagnosis of MG in Atatürk University Faculty of Medicine, Department of Neurology were included in the study. Serum 25(OH)D, vitamin B12 and folic acid levels were measured by taking blood from the antecubital vein in two different time periods, during the myasthenic crisis and during the non-crisis period, and periods were compared among themselves.
Results: During the myasthenic crisis period, 25(OH)D level was 11.54 (1.08-50.33) ng/mL, vitamin B12 level was 299.5 (104-964) pg/mL, and folic acid level was 9.54±5.08 ng/mL. In the non-crisis period, 25(OH)D level was 18.74 (6.63-30.19) ng/mL, vitamin B12 level was 266 (119-678) pg/mL and folic acid level is 10.26±3.5 ng/mL. During the myasthenic crisis period, 25(OH)D vitamin levels of the patients were statistically significantly lower than the non-crisis period (p<0.05). There was no difference between the two periods in terms of vitamin B12 and folic acid (p>0.05).
Conclusion: Low VD levels can be a facilitating factor in worsening myasthenic symptoms and entering myasthenic crisis. The use of VD supplements in MG patients with low VD levels may be beneficial in terms of protection from myasthenic crisis. Despite the limitations of our study, such as the small number of patients and the fact that 25(OH)D levels were not adjusted for seasonal effects, this study is the first study showing that VD levels are lower in the myasthenic crisis period than in the non-crisis period.

Keywords

Myasthenia gravis, myasthenic crisis, 25- hydroxy vitamin D, vitamin B12, folic acid

References

• Rabinstein AA, Mueller-Kronast N. Risk of extubation failure in patients with myasthenic crisis. Neurocrit Care 2005; 3: 213
• Szodoray P, Nakken B, Gaal J, et al. The complex role of vitamin D in autoimmune diseases. Scand J Immunol 2008; 68: 261-9.
• Holick M.F. Vitamin D deficiency. N Engl J Med 2007; 357: 266–81.
• Doğan M, Doğan AG. Vitamin D yetersizliği ve eksikliğine güncel yaklaşım. J Health Sci Med 2019; 2: 58-61.
• Depeint F, Bruce WR, Shangari N, Mehta R, O’Brien PJ. Mitochondrial function and toxicity: role of B vitamins on the one-carbon transfer pathways. Chem Biol Interact 2006; 163: 113-32.
• Elmadfa I, Meyer AL. The role of the status of selected micronutrients in shaping the immune function. Endocr Metab Immune Disord Drug Targets 2019; 19: 1100-15.
• Wu CH, Huang TC, Lin BF. Folate deficiency affects dendritic cell function and subsequent T helper cell differentiation. J Nutr Biochem 2017; 41: 65-72.
• Makino E, Fukuyama T, Watanabe Y, et al. Subacute oral administration of folic acid elicits anti-inflammatory response in a mouse model of allergic dermatitis. J Nutr Biochem 2019; 67: 14-9.
• Aricha R, Feferman T, Scott HS, Souroujon MC, Berrih-Aknin S, Fuchs S. The susceptibility of Aire(-/-) mice to experimental myasthenia gravis involves alterations in regulatory T cells. J Autoimmun 2011; 36: 16-24.
• Mok CC, Birmingham DJ, Ho LY, Hebert LA, Song H, Rovin BH. Vitamin D deficiency as marker for disease activity and damage in systemic lupus erythematosus: a comparison with anti-dsDNA and anti-C1q. Lupus 2012; 21: 36-42.
• Varenna M, Manara M, Cantatore FP, et al. Determinants and effects of vitamin D supplementation on serum 25-hydroxy-vitamin D levels in patients with rheumatoid arthritis. Clin Exp Rheumatol 2012; 30: 714-9.
• Smolders J, Menheere P, Kessels A, Damoiseaux J, Hupperts R. Association of vitamin D metabolite levels with relapse rate and disability in multiple sclerosis. Mult Scler 2008; 14: 1220-4.
• Dügeroğlu H. Evaluation of 25-hydroxy vitamin D levels in COVID- 19 positive patients J Health Sci Med 2021; 4: 931-5.
• Kang SY, Kang JH, Choi JC, Song SK, Oh JH. Low serum vitamin D levels in patients with myasthenia gravis. J Clin Neurosci 2018; 50: 294-7.
• Justo ME, Aldecoa M, Cela E, et al. Low vitamin D serum levels in a cohort of myasthenia gravis patients in Argentina. Photochem Photobiol 2021; 10.1111/php.13432. doi:10.1111/php.13432
• Askmark H, Haggård L, Nygren I, Punga AR. Vitamin D deficiency in patients with myasthenia gravis and improvement of fatigue after supplementation of vitamin D3: a pilot study. Eur J Neurol 2012; 19: 1554-60.
• Richman DP, Agius MA. Acquired myasthenia gravis: immunopathology. Neurol Clin 1994; 12: 273-84.
• Chang KH, Lyu RK, Ro LS, Wu YR, Chen CM. Coexistence of pernicious anemia and myasthenia gravis--a rare combination of autoimmune diseases in Taiwan. J Formos Med Assoc 2006;105: 946-9.
• Khademolhosseini S, Springsted E, Pourshahid S, Giri B. Coexistence of pernicious anemia and myasthenia gravis presenting as dyspnea. Cureus 2021; 13: e15295.
• Krol TC. Myasthenia gravis, pernicious anemia, and Hashimoto’s thyroiditis. Arch Neurol 1979; 36: 594-5.
• Zittoun J, Tulliez M, Estournet B, Goulon M. Humoral and cellular immunity to intrinsic factor in myasthenia gravis. Scand J Haematol 1979; 23: 442-8.
• Wintergerst ES, Maggini S, Hornig DH. Contribution of selected vitamins and trace elements to immune function. Ann Nutr Metab 2007; 51: 301-23.
• Tamura J, Kubota K, Murakami H, et al. Immunomodulation by vitamin B12: augmentation of CD8+ T lymphocytes and natural killer (NK) cell activity in vitamin B12-deficient patients by methyl-B12 treatment. Clin Exp Immunol 1999; 116: 28-32.
• 24.Hartmann J, Rivner MH. Methotrexate in myasthenia gravis. Clin Neurophysiol 2009; 120: e123–e124.
• Koźmiński P, Halik PK, Chesori R, Gniazdowska E. Overview of dual-acting drug methotrexate in different neurological diseases, autoimmune pathologies and cancers. Int J Mol Sci 2020; 21: 3483.
• Pasnoor M, He J, Herbelin L, et al. A randomized controlled trial of methotrexate for patients with generalized myasthenia gravis. Neurology 2016; 87: 57-64.