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we present the case of a patient in whom these entities were confirmed to coexist&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0030" class="elsevierStylePara elsevierViewall">A previously healthy mixed race female patient aged 24 years&#44; from Ibagu&#233;&#44; Colombia&#44; who in August 2016 was diagnosed extra-institutionally with SLE by 1&#58;160 ANA indirect immunofluorescence&#44; debuting with the following clinical manifestation&#58; serous involvement&#44; arthritis&#44; anaemia&#44; alopecia&#44; convulsive crises and swiftly progressing glomerulonephritis&#44; requiring support with renal replacement haemodialysis one month after diagnosis&#46; She received outpatient treatment with prednisolone 30<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; without taking a renal biopsy&#44; and the rest of her autoimmunity profile was unknown &#40;ENA&#44; anticardiolipins&#44; lupus anticoagulant&#41;&#46; After 3 months she required hospitalisation once again in another institution in the intensive care unit &#40;ICU&#41; due to respiratory failure secondary to pneumonia and an episode of acute weakness that was gradually resolved with systemic steroid to treat the SLE&#44; without performing additional studies&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">She was referred to the Emergency department of our institution due to symptoms that had evolved over 10 days&#44; with a cough and purulent expectoration associated with fever that was not quantified&#44; shivering&#44; tachycardia and the appearance of vesicular-type lesions on the upper lip and right nasal ala&#46; The day she was admitted she had a focal crisis with alteration in attention and self-limiting bilateral spreading rigidity&#44; so that treatment with lacosamide commenced&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">At admission she had raised arterial pressure &#40;204&#47;115<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; tachycardia &#40;115 lpm&#41;&#44; evidence of ulcerated vesicular lesions on the upper lip and right nasal ala and slight rale in the base of the right lung without signs of respiratory difficulty&#46; Neurological examination showed reduction in the visual acuity of the left eye&#44; explained by serous central choroidopathy&#44; without other findings&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Paraclinical tests at admission found anaemia with haemoglobin at 9&#46;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; platelets at 196&#44;500<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span>&#44; urine analysis with no active sediment&#44; renal ultrasound scan with cortical atrophy&#44; so that it was not possible to characterise the type of lupus nephritis&#44; complement and anti-DNA within normal limits&#44; ruling out lupus activity&#44; with normal thyroid function&#46; Consolidation of the middle lobe was confirmed&#44; ruling out additional complications or other abnormal findings by means of high resolution thoracic tomography&#46; Antibiotic treatment was commenced with clarithromycin and piperacillin tazobactam for pneumonia with risk factors for resistant germs&#44; due to a recommendation by Infectiology&#44; as well as acyclovir for the presence of skin lesions compatible with herpes zoster infection&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Three days after admission fluctuating episodes of predominantly left side bilateral ptosis were detected &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; positive ice pack test&#44; positive fatigability test&#44; eye movements with left supraduction deficit&#44; vertical binocular diplopia&#44; moderate facial diparesia&#44; hypophonia&#44; neck flexoextensor weakness in 2&#47;5 and counted up to 4&#44; without apendicular muscle involvement or other findings in the neurological examination&#46; Due to the presence of these manifestations involvement of the neuromuscular junction was suspected&#44; and the repetitive stimulation test was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; showing a post-synaptic disorder in the neuromuscular junction&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The course of a myasthemic crisis was then considered&#44; triggered by the community-acquired pneumonia&#44; with the antecedent of SLE&#44; thereby forming a polyautoimmunity syndrome in which the lack of SLE activity was striking&#46; She was transferred to the ICU due to the risk of respiratory failure and stayed there for 8 days&#44; completing 5 plasma replacement therapy sessions with no complications and resolution of the myasthenic crisis 15 days after the start of symptoms and treatment&#46; She was discharged with immunomodulator treatment with a corticoid&#44; azathioprine and an antimalarial drug&#44; together with symptomatic treatment with pyridostigmine&#44; with the indication to test for anti-acetylcholine receptor antibodies&#59; however&#44; the patient did not attend the following check-ups&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The coexistence of MG and SLE represents a clinical challenge due to the possible differential diagnoses that may be involved when confronted by muscle involvement in patients with SLE&#46; Myopathies in patients with SLE may be manifestations of this disease&#44; or they may be associated with other autoimmune diseases&#44; especially polymyositis&#44; dermatomyositis&#44; thyroid diseases&#44; myotoxicity due to medication and&#44; less frequently&#44; they may be associated with MG as an expression of polyautoimmunity&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A large proportion of the studies that report on the association between SLE and MG cover cohorts of patients with MG&#44; evaluating polyautoimmunity with other AD&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6&#44;7</span></a> Works such as the one by Rojas-Villarraga et al&#46;&#44; which seeks to evaluate factors associated with polyautoimmunity in SLE&#44; do not identify any clear association with MG<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#59; nevertheless&#44; a study performed in Norway in 1984 found that of 48 patients diagnosed with MG&#44; 11 patients had another AD&#44; of whom 4 patients &#40;8&#46;3&#37;&#41; were diagnosed SLE&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The description by Tanovska et al&#46; shows that 15&#37; of the patients diagnosed MG had another AD&#44; the most frequent of which was autoimmune thyroid disease&#44; this being one of the &#8220;chaperone diseases&#8221; described by Anaya et al&#46; Bekircan-Kurt et al&#46; reported that 73&#46;3&#37; of the patients with another AD had been diagnosed before MG itself&#44; and in our report the diagnosis of SLE preceded that of MG&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6&#44;8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The data vary respecting the primary disease&#44; with a prevalence of up to 1&#46;3&#37; of MG in patients with SLE&#44; and up to 8&#37; of SLE in patients with MG&#59; nevertheless&#44; the high prevalence in women was the common factor&#46; The group of Jallouli et al&#46; showed that the clinical manifestation of SLE was less severe in those who were also diagnosed MG&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Patients who are treated by thymectomy for MG have widely been described to possibly have a predisposition for subsequently developing SLE&#59; this may be due to a loss of central tolerance and excess production of antibodies&#59; however&#44; to date there has been no research to study this relationship in greater depth&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Another important and interesting phenomenon in autoimmunity is familial aggregation&#46; This has been described in all of the AD&#44; and MG is not an exception&#46; In GLADEL cohort patients as well as in patients with MG&#44; familial autoimmunity has been found to be a risk factor for developing the same AD as well as for other types of AD&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10&#44;13&#44;14</span></a> The work by Liu et al&#46; in Taiwan&#44; in an individual the RR with a first degree family member affected by MG was 2&#46;18 &#40;1&#46;53&#8211;3&#46;12&#41; for SLE&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Although it is not common for these disorders to present together&#44; in different cases it has been possible to see an association between SLE and MG&#44; so that it is important to think of MG as a differential diagnosis when an individual with SLE has symptoms of fluctuating muscle weakness and fatigability&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Confirming polyimmunity and familial aggregation is therefore clinically relevant for differential diagnosis and proper management of its manifestations and complications&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interests</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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            0 => "Systemic lupus erythematosus"
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            2 => "Polyautoimmunity"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The relevance of polyautoimmunity&#44; defined as the presence of two or more autoimmune diseases in the same individual&#44; is one of the issues not yet elucidated in medical practice&#46; The coexistence of myasthenia gravis &#40;MG&#41; and systemic lupus erythematosus &#40;SLE&#41; is a clinical challenge due to the possible differential diagnoses of muscle involvement in patients with SLE&#46; We present the case of a patient who came to the emergency room of Hospital Universitario San Ignacio in Bogot&#225;&#44; Colombia&#44; with a previous diagnosis of SLE&#44; who developed acute weakness in the context of a systemic infection&#44; with a clinical and electrophysiological diagnosis of MG&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La relevancia cl&#237;nica de la poliautoinmunidad&#44; definida como la presencia de dos o m&#225;s enfermedades autoinmunes en un mismo individuo&#44; es uno de los temas aun sin dilucidar en la pr&#225;ctica m&#233;dica&#46; La coexistencia entre miastenia gravis &#40;MG&#41; y lupus eritematoso sist&#233;mico&#40;LES&#41; supone un reto cl&#237;nico por los posibles diagn&#243;sticos diferenciales dados al momento de abordar el compromiso muscular en pacientes con LES&#46; Presentamos el caso de una paciente que consult&#243; a urgencias del Hospital Universitario San Ignacio de Bogot&#225;&#44; Colombia&#44; con diagn&#243;stico previo de LES&#44; que desarrolla un s&#237;ndrome de debilidad aguda en el contexto de una infecci&#243;n sist&#233;mica&#44; haciendo diagn&#243;stico cl&#237;nico y electrofisiol&#243;gico de MG&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a-Alfonso C&#44; Bernal-Mac&#237;as S&#44; Garc&#237;a-Pardo Y&#44; Patricia Mill&#225;n S&#44; D&#237;az MC&#46; Coexistencia de lupus eritematoso sist&#233;mico y miastenia gravis&#46; Una expresi&#243;n infrecuente de poliautoinmunidad&#46; Reumatol Clin&#46; 2020&#59;16&#58;502&#8211;505&#46;</p>"
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                          "etal" => true
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Case Report
Coexistence of systemic lupus erythematosus and myasthenia gravis: an unusual case of polyautoimmunity
Coexistencia de lupus eritematoso sistémico y miastenia gravis. Una expresión infrecuente de poliautoinmunidad
Carolina García-Alfonsoa, Santiago Bernal-Macíasb,
Corresponding author
, Yulieth García-Pardoc, Sonia Patricia Millána, María-Claudia Díazd
a Unidad de Neurología, Hospital Universitario San Ignacio, Bogotá, Colombia
b Departamento de Medicina Interna, Hospital Universitario San Ignacio, Bogotá, Colombia
c Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
d Unidad de Reumatología, Hospital Universitario San Ignacio, Bogotá, Colombia
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The autoimmune diseases &#40;AD&#41; correspond to a heterogeneous group of entities in which a loss of immunological self-tolerance occurs&#44; manifesting clinically as organ-specific or systemic compromise&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The presence of similar physiopathological mechanisms associated with genetic factors explains the theory of polyimmunity&#44; defined as the presence of 2 or more AD in a single individual&#46; The work by Anaya et al&#46; concludes that there are autoimmunity &#8220;chaperones&#8221;&#44; and that a history of familial autoimmunity supports the hypothesis that it is not fortuitous&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Myasthenia gravis &#40;MG&#41; is an organ-specific AD that is characterised by dysfunction of the neuromuscular link secondary to the presence of antibodies&#44; with clinical manifestations such as a tendency to fatigue and fluctuating muscle weakness&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The thymus plays a central physiopathological role in this entity due to the presence of antigens and the activation of T and B cells that correlate with the production of acetylcholine receptor antibodies&#46; It has two forms of presentation&#58; the first peak occurs at from 20 to 30 years old and predominates in women&#44; while the second peak occurs after the age of 60 years old and predominates in men&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">On the other hand&#44; systemic lupus erythematosus &#40;SLE&#41; is one of the AD per excellence&#44; and it is more prevalent in young women&#46; It leads to systemic compromise due to the production of antibodies&#44; the deposit of immune complexes and the activation of the complement cascade&#44; leading to multiple organ damage&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The frequency with which MG and SLE coexist is variable&#44; and reported rates of incidence run from the 3&#46;78&#37; of patients with SLE reported by Bekircan-Kurt et al&#46;&#44; in a cohort with MG&#44; up to 7&#46;7&#37;&#44; with a higher prevalence among women&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> A prevalence of polyautoimmunity is reported of up to 15&#37; in cohorts of patients with MG&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Taking the above considerations into account&#44; we present the case of a patient in whom these entities were confirmed to coexist&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0030" class="elsevierStylePara elsevierViewall">A previously healthy mixed race female patient aged 24 years&#44; from Ibagu&#233;&#44; Colombia&#44; who in August 2016 was diagnosed extra-institutionally with SLE by 1&#58;160 ANA indirect immunofluorescence&#44; debuting with the following clinical manifestation&#58; serous involvement&#44; arthritis&#44; anaemia&#44; alopecia&#44; convulsive crises and swiftly progressing glomerulonephritis&#44; requiring support with renal replacement haemodialysis one month after diagnosis&#46; She received outpatient treatment with prednisolone 30<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; without taking a renal biopsy&#44; and the rest of her autoimmunity profile was unknown &#40;ENA&#44; anticardiolipins&#44; lupus anticoagulant&#41;&#46; After 3 months she required hospitalisation once again in another institution in the intensive care unit &#40;ICU&#41; due to respiratory failure secondary to pneumonia and an episode of acute weakness that was gradually resolved with systemic steroid to treat the SLE&#44; without performing additional studies&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">She was referred to the Emergency department of our institution due to symptoms that had evolved over 10 days&#44; with a cough and purulent expectoration associated with fever that was not quantified&#44; shivering&#44; tachycardia and the appearance of vesicular-type lesions on the upper lip and right nasal ala&#46; The day she was admitted she had a focal crisis with alteration in attention and self-limiting bilateral spreading rigidity&#44; so that treatment with lacosamide commenced&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">At admission she had raised arterial pressure &#40;204&#47;115<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; tachycardia &#40;115 lpm&#41;&#44; evidence of ulcerated vesicular lesions on the upper lip and right nasal ala and slight rale in the base of the right lung without signs of respiratory difficulty&#46; Neurological examination showed reduction in the visual acuity of the left eye&#44; explained by serous central choroidopathy&#44; without other findings&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Paraclinical tests at admission found anaemia with haemoglobin at 9&#46;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; platelets at 196&#44;500<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">6</span>&#44; urine analysis with no active sediment&#44; renal ultrasound scan with cortical atrophy&#44; so that it was not possible to characterise the type of lupus nephritis&#44; complement and anti-DNA within normal limits&#44; ruling out lupus activity&#44; with normal thyroid function&#46; Consolidation of the middle lobe was confirmed&#44; ruling out additional complications or other abnormal findings by means of high resolution thoracic tomography&#46; Antibiotic treatment was commenced with clarithromycin and piperacillin tazobactam for pneumonia with risk factors for resistant germs&#44; due to a recommendation by Infectiology&#44; as well as acyclovir for the presence of skin lesions compatible with herpes zoster infection&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Three days after admission fluctuating episodes of predominantly left side bilateral ptosis were detected &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; positive ice pack test&#44; positive fatigability test&#44; eye movements with left supraduction deficit&#44; vertical binocular diplopia&#44; moderate facial diparesia&#44; hypophonia&#44; neck flexoextensor weakness in 2&#47;5 and counted up to 4&#44; without apendicular muscle involvement or other findings in the neurological examination&#46; Due to the presence of these manifestations involvement of the neuromuscular junction was suspected&#44; and the repetitive stimulation test was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; showing a post-synaptic disorder in the neuromuscular junction&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The course of a myasthemic crisis was then considered&#44; triggered by the community-acquired pneumonia&#44; with the antecedent of SLE&#44; thereby forming a polyautoimmunity syndrome in which the lack of SLE activity was striking&#46; She was transferred to the ICU due to the risk of respiratory failure and stayed there for 8 days&#44; completing 5 plasma replacement therapy sessions with no complications and resolution of the myasthenic crisis 15 days after the start of symptoms and treatment&#46; She was discharged with immunomodulator treatment with a corticoid&#44; azathioprine and an antimalarial drug&#44; together with symptomatic treatment with pyridostigmine&#44; with the indication to test for anti-acetylcholine receptor antibodies&#59; however&#44; the patient did not attend the following check-ups&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The coexistence of MG and SLE represents a clinical challenge due to the possible differential diagnoses that may be involved when confronted by muscle involvement in patients with SLE&#46; Myopathies in patients with SLE may be manifestations of this disease&#44; or they may be associated with other autoimmune diseases&#44; especially polymyositis&#44; dermatomyositis&#44; thyroid diseases&#44; myotoxicity due to medication and&#44; less frequently&#44; they may be associated with MG as an expression of polyautoimmunity&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A large proportion of the studies that report on the association between SLE and MG cover cohorts of patients with MG&#44; evaluating polyautoimmunity with other AD&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6&#44;7</span></a> Works such as the one by Rojas-Villarraga et al&#46;&#44; which seeks to evaluate factors associated with polyautoimmunity in SLE&#44; do not identify any clear association with MG<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#59; nevertheless&#44; a study performed in Norway in 1984 found that of 48 patients diagnosed with MG&#44; 11 patients had another AD&#44; of whom 4 patients &#40;8&#46;3&#37;&#41; were diagnosed SLE&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The description by Tanovska et al&#46; shows that 15&#37; of the patients diagnosed MG had another AD&#44; the most frequent of which was autoimmune thyroid disease&#44; this being one of the &#8220;chaperone diseases&#8221; described by Anaya et al&#46; Bekircan-Kurt et al&#46; reported that 73&#46;3&#37; of the patients with another AD had been diagnosed before MG itself&#44; and in our report the diagnosis of SLE preceded that of MG&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6&#44;8</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The data vary respecting the primary disease&#44; with a prevalence of up to 1&#46;3&#37; of MG in patients with SLE&#44; and up to 8&#37; of SLE in patients with MG&#59; nevertheless&#44; the high prevalence in women was the common factor&#46; The group of Jallouli et al&#46; showed that the clinical manifestation of SLE was less severe in those who were also diagnosed MG&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Patients who are treated by thymectomy for MG have widely been described to possibly have a predisposition for subsequently developing SLE&#59; this may be due to a loss of central tolerance and excess production of antibodies&#59; however&#44; to date there has been no research to study this relationship in greater depth&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Another important and interesting phenomenon in autoimmunity is familial aggregation&#46; This has been described in all of the AD&#44; and MG is not an exception&#46; In GLADEL cohort patients as well as in patients with MG&#44; familial autoimmunity has been found to be a risk factor for developing the same AD as well as for other types of AD&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10&#44;13&#44;14</span></a> The work by Liu et al&#46; in Taiwan&#44; in an individual the RR with a first degree family member affected by MG was 2&#46;18 &#40;1&#46;53&#8211;3&#46;12&#41; for SLE&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Although it is not common for these disorders to present together&#44; in different cases it has been possible to see an association between SLE and MG&#44; so that it is important to think of MG as a differential diagnosis when an individual with SLE has symptoms of fluctuating muscle weakness and fatigability&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Confirming polyimmunity and familial aggregation is therefore clinically relevant for differential diagnosis and proper management of its manifestations and complications&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interests</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The relevance of polyautoimmunity&#44; defined as the presence of two or more autoimmune diseases in the same individual&#44; is one of the issues not yet elucidated in medical practice&#46; The coexistence of myasthenia gravis &#40;MG&#41; and systemic lupus erythematosus &#40;SLE&#41; is a clinical challenge due to the possible differential diagnoses of muscle involvement in patients with SLE&#46; We present the case of a patient who came to the emergency room of Hospital Universitario San Ignacio in Bogot&#225;&#44; Colombia&#44; with a previous diagnosis of SLE&#44; who developed acute weakness in the context of a systemic infection&#44; with a clinical and electrophysiological diagnosis of MG&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La relevancia cl&#237;nica de la poliautoinmunidad&#44; definida como la presencia de dos o m&#225;s enfermedades autoinmunes en un mismo individuo&#44; es uno de los temas aun sin dilucidar en la pr&#225;ctica m&#233;dica&#46; La coexistencia entre miastenia gravis &#40;MG&#41; y lupus eritematoso sist&#233;mico&#40;LES&#41; supone un reto cl&#237;nico por los posibles diagn&#243;sticos diferenciales dados al momento de abordar el compromiso muscular en pacientes con LES&#46; Presentamos el caso de una paciente que consult&#243; a urgencias del Hospital Universitario San Ignacio de Bogot&#225;&#44; Colombia&#44; con diagn&#243;stico previo de LES&#44; que desarrolla un s&#237;ndrome de debilidad aguda en el contexto de una infecci&#243;n sist&#233;mica&#44; haciendo diagn&#243;stico cl&#237;nico y electrofisiol&#243;gico de MG&#46;</p></span>"
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