Which of the following is the characteristic symptom of myasthenia gravis?
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RPL currently serves on an Advisory Board for Argenx for myasthenia gravis (MG), and was an Advisory Board member for Argenx (developing a clinical trial for chronic inflammatory demyelinating polyneuropathy [CIDP]). RPL has been reimbursed by Argenx the manufacturer of efartigimod for serving on a clinical advisory board. RPL has worked with Alexion (testing a treatment for MG); Novartis (design of research related to primary progressive multiple sclerosis [MS] vs. secondary progressive MS); Horizon Pharmaceuticals (advising on MG and neuromyelitis optica spectrum disorder); Takeda (advising on autoimmune diseases); GLG Consulting, Putnam Consulting, Slingshot Consulting, Haven Consulting, Clearview Consulting, Alpha Sites Consulting, and Insights Consulting (providing insights on the current and future treatments of several neuroimmunologic diseases including MS, MG, Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, and neuromyelitis optica spectrum disorder). RPL has presented several CME talks for companies with multiple sources of support (no direct payments to RPL). RPL has received clinical trial grants (no direct payments) for studies in MG (Alexion, Argenx, Ra Pharmaceuticals) and MS (Novartis, Teva, Genentech/Roche, Chugai). He has received royalties from Blackwell Press as an editor of the textbook International Neurology, and from Oxford University Press as an editor of a book, Neuroimmunology. RPL is an author of several papers cited in this topic. Show
Myasthenia gravis is characterized by episodic muscle weakness and easy fatigability caused by autoantibody- and cell-mediated destruction of acetylcholine receptors. It is more common among young women and older men but may occur in men or women at any age. Symptoms worsen with muscle activity and lessen with rest. Diagnosis is by measurement of serum acetylcholine receptor (AChR) antibody levels, electromyography, and bedside tests (ice pack test, rest test). Treatment includes anticholinesterase drugs, immunosuppressants, corticosteroids, plasma exchange, IV immune globulin, and possibly thymectomy. (See also Overview of Peripheral Nervous System Disorders Overview of Peripheral Nervous System Disorders The peripheral nervous system refers to parts of the nervous system outside the brain and spinal cord. It includes the cranial nerves and spinal nerves from their origin to their end. The anterior... read more .) Myasthenia gravis develops most commonly in women aged 20 to 40 and men aged 50 to 80, but it can occur at any age, including childhood. Myasthenia gravis results from an autoimmune attack on postsynaptic acetylcholine receptors, which disrupts neuromuscular transmission. The trigger for autoantibody production is unknown, but the disorder is associated with abnormalities of the thymus, autoimmune hyperthyroidism, and other autoimmune disorders (eg, rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more The role of the thymus in myasthenia is unclear, but 65% of patients have thymic hyperplasia, and 10% have a thymoma. About half of the thymomas are malignant. Precipitating factors for myasthenia gravis include
Abnormal antibodiesMost patients with myasthenia gravis develop antibodies to acetylcholine receptors (AChRs); these antibodies bind to AChRs on the postsynaptic membrane at the neuromuscular junction and interrupt neuromuscular transmission. About 10 to 20% of patients with generalized myasthenia have no antibodies to acetylcholine receptors (AChR) in serum. Up to 50% of these AChR antibody‒negative patients have antibodies to muscle-specific receptor tyrosine kinase (MuSK), a surface membrane enzyme that helps AChR molecules aggregate during development of the neuromuscular junction. However, anti-MuSK antibodies do not occur in most patients with AChR antibodies or with isolated ocular myasthenia. The clinical significance of anti-MuSK antibodies is still under study, but patients with these antibodies are much less likely to have thymic hyperplasia or a thymoma, may be less responsive to anticholinesterase drugs, and may require more aggressive early immunotherapy than patients who have AChR antibodies. Uncommon formsOcular myasthenia gravis involves only extraocular muscles. It represents about 15% of cases. Congenital myasthenia is a rare autosomal recessive disorder that begins in childhood. It is not immune-mediated and results from presynaptic or postsynaptic abnormalities, including the following:
Ophthalmoplegia is common in patients with congenital myasthenia. Neonatal myasthenia affects 12% of infants born to women with myasthenia gravis. It is due to IgG antibodies that passively cross the placenta. It causes generalized muscle weakness, which resolves in days to weeks as antibody titers decline. Thus, treatment is usually supportive. Symptoms and Signs of Myasthenia GravisThe most common symptoms of myasthenia gravis are
Weakness resolves when the affected muscles are rested but recurs when they are used again. Weakness due to myasthenia lessens in cooler temperatures. Ocular muscles are affected initially in 40% of patients and eventually in 85% and are the only muscles affected in 15%. If generalized myasthenia is going to develop after ocular symptoms, it develops in 78% of patients within 1 year and in 94% within the first 3 years. Hand grip may alternate between weak and normal (milkmaid’s grip). Neck muscles may become weak. Proximal limb weakness is common. Some patients present with bulbar symptoms (eg, altered voice, nasal regurgitation, choking, dysphagia). Sensation and deep tendon reflexes are normal. Manifestations fluctuate in intensity over minutes to hours to days. Myasthenic crisis, a severe generalized quadriparesis or life-threatening respiratory muscle weakness, occurs in about 15 to 20% of patients at least once in their life. It is often due to a supervening infection that reactivates the immune system. Once respiratory insufficiency begins, respiratory failure may occur rapidly. Cholinergic crisis is muscular weakness that can result when the dose of anticholinesterase drugs (eg, neostigmine, pyridostigmine) is too high. A mild crisis may be difficult to differentiate from worsening myasthenia. Severe cholinergic crisis can usually be differentiated because it, unlike myasthenia gravis, results in muscle fasciculations, increased lacrimation and salivation, tachycardia, and diarrhea. Diagnosis of Myasthenia Gravis
The diagnosis of myasthenia gravis is suggested by symptoms and signs and confirmed by tests. Bedside testingThe traditional anticholinesterase test, done at bedside and using the short-acting (< 5 minutes) drug edrophonium, is not used in the US and in many other countries, and edrophonium is no longer available in the US. Because weakness due to myasthenia lessens in cooler temperature, patients with ptosis can be tested using the ice pack test. For this test, an icepack is applied to a patient's closed eyes for 2 minutes, then removed. A positive result is full or partial resolution of ptosis. The ice pack test usually does not work if patients have ophthalmoparesis. Patients with opthalmoparesis can be tested using the rest test. For this test, patients are asked to lie quietly in a dark room for 5 minutes with their eyes closed. If ophthalmoparesis resolves after this rest, the result is positive. Antibody testing and electromyographyEven if a bedside test is unequivocally positive, one or both of the following are required to confirm the diagnosis:
AChR antibodies are present in 80 to 90% of patients with generalized myasthenia but in only 50% with the ocular form. Antibody levels do not correlate with disease severity. Up to 50% of patients without AChR antibodies test positive for anti-MuSK antibodies. EMG using repetitive stimuli (2 to 3/seconds) shows a > 10% decrease in amplitude of the compound muscle action potential response in 60% of patients. Single-fiber EMG can detect abnormal neuromuscular transmission in > 95%. Further testingOnce myasthenia is diagnosed, CT or MRI of the thorax should be done to check for thymic hyperplasia and a thymoma. Other tests should be done to screen for autoimmune disorders frequently associated with myasthenia gravis (eg, pernicious anemia Vitamin B12 Deficiency Dietary vitamin B12 deficiency usually results from inadequate absorption, but deficiency can develop in vegans who do not take vitamin supplements. Deficiency causes megaloblastic anemia, damage... read more , autoimmune hyperthyroidism, RA Diagnosis Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more Patients in myasthenic crisis should be evaluated for an infectious trigger. Bedside pulmonary function tests (eg, forced vital capacity) help detect impending respiratory failure. Treatment of Myasthenia Gravis
In patients with congenital myasthenia, anticholinesterase drugs and immunomodulating treatments are not beneficial and should be avoided. Patients with respiratory failure require intubation Tracheal Intubation Most patients requiring an artificial airway can be managed with tracheal intubation, which can be Orotracheal (tube inserted through the mouth) Nasotracheal (tube inserted through the nose)... read more and mechanical ventilation Overview of Mechanical Ventilation Mechanical ventilation can be Noninvasive, involving various types of face masks Invasive, involving endotracheal intubation Selection and use of appropriate techniques require an understanding... read more . Symptomatic treatmentAnticholinesterase drugs are the mainstay of symptomatic treatment but do not alter the underlying disease process. Moreover, they rarely relieve all symptoms, and myasthenia may become refractory to these drugs. Pyridostigmine is begun at 60 mg orally every 3 to 4 hours and titrated up to a maximum of 120 mg/dose based on symptoms. When parenteral therapy is necessary (eg, because of dysphagia), neostigmine (1 mg = 60 mg of pyridostigmine) may be substituted. Anticholinesterase drugs can cause abdominal cramps and diarrhea, which are treated with oral atropine 0.4 to 0.6 mg (given with pyridostigmine or neostigmine) or propantheline 15 mg 3 to 4 times a day. Patients who have been responding well to treatment and then deteriorate require respiratory support because they may have cholinergic crisis, and anticholinesterase drugs must be stopped for several days. Immunomodulating treatmentImmunosuppressants (eg, corticosteroids, azathioprine, cyclosporine) interrupt the autoimmune reaction and slow the disease course, but they do not relieve symptoms rapidly. Thus, patients with myasthenic crisis require treatment with IVIG or plasma exchange. After being given IVIG 400 mg/kg once a day for 5 days, 70% of patients improve in 1 to 2 weeks. Effects may last 1 to 2 months. Plasma exchange (eg, 5 exchanges of 3 to 5 L plasma over 7 to 14 days) can have similar effects. Corticosteroids are necessary as maintenance therapy for many patients but have little immediate effect in myasthenic crisis. Over half of patients worsen acutely after starting high-dose corticosteroids. Initially, prednisone 10 mg orally once a day is given; dose is increased by 10 mg weekly up to 60 mg, which is given for about 2 months, then tapered slowly. Improvement may take several months; then, the dose should be reduced to the minimum necessary to control symptoms. Azathioprine 2.5 to 3.5 mg/kg orally once a day may be as effective as corticosteroids, although significant benefit may not occur for many months. Cyclosporine 2 to 2.5 mg/kg orally twice a day may allow the corticosteroid dose to be reduced. These drugs require the usual precautions. Other drugs that may be beneficial include methotrexate, cyclophosphamide, and mycophenolate mofetil. For patients with refractory disease, monoclonal antibodies (eg, rituximab, eculizumab) and the new modified monoclonal IgG1 Fc fragment efartigimod may be beneficial but are costly. Thymectomy may be indicated for patients with generalized myasthenia if they are < 80 years; it should be done in all patients with a thymoma. Subsequently, in 80%, remission occurs or the maintenance drug dose can be lowered. Plasma exchange Plasma exchange Apheresis refers to the process of separating the cellular and soluble components of blood using a machine. Apheresis is often done on donors where whole blood is centrifuged to obtain individual... read more or IVIG (the usual treatment for myasthenic crisis) may also be useful if patients are unresponsive to drugs before thymectomy. Key Points
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