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Myasthenia Gravis

Erb Goldflam Syndrome

Myasthenia gravis is a rare autoimmune disorder of the neuromuscular junction characterized by varying degrees of weakness of the voluntary muscles.


Presentation

Myasthenia gravis affects children and neonates as well as adults. There will be weakness noticed in children too. There might be a weak cry and difficult movement of muscles or delayed milestones.

In adults, extraocular muscle weakness is the most common affection seen in maximum patients [4]. The hallmark of the myasthenia gravis is fatiguability or tiredness of the voluntary muscles [5]. Many patients present with bulbar muscle weakness and limb weakness which is often seen first in the proximal limbs and then in distal limbs. Since it is a chronic disorder, signs and symptoms are visible only after there is 30% reduction or destruction of the receptor sites and till then there is no evident sign.

Typically, extraocular muscle weakness is asymmetric and can be noticed easily. Drooping eyelids or ptosis occurs after straining the eyes for a long time as muscles give up after continuously using them due to a deficiency of acetylcholine at the neuromuscular junction.

Other common symptoms occurring out of fatiguability are slurred speech, diplopia or blurred vision, difficulty in chewing and dysphagia, weakness in arms and legs, chronic muscle fatigue, dyspnea, unstable gait, dysarthria i.e. difficulty in speaking or talking and impaired speech.

Weakness of muscles is typically least in the morning and progresses as the day progresses. Weakness increases as there is increased exertion and gets better with rest. Proximal muscle weakness is more often seen than distal muscle weakness.

Hoarseness
  • This case emphasizes the need to consider systemic diseases in the differential diagnosis of hoarseness and demonstrates the need for careful follow-up in such patients.[ncbi.nlm.nih.gov]
  • Double vision Difficulty maintaining a steady gaze Eyelid drooping Other symptoms include: A drooping head Difficulty breathing Difficulty chewing and swallowing Difficulty climbing stairs Difficulty talking Facial paralysis Difficulty lifting objects Hoarseness[bmc.org]
  • Symptoms of MG can include: trouble talking problems walking up stairs or lifting objects facial paralysis difficulty breathing due to muscle weakness difficulty swallowing or chewing fatigue hoarse voice drooping of eyelids double vision Not everyone[healthline.com]
  • […] swallowing difficulty, causing frequent gagging, choking, or drooling Difficulty climbing stairs, lifting objects, or rising from a seated position Difficulty talking Drooping head and eyelids Facial paralysis or weakness of the facial muscles Fatigue Hoarseness[mountsinai.org]
Fatigue
  • […] residual problematic fatigue.[ncbi.nlm.nih.gov]
  • Abnormal amplitude decrement was found in 54% of patients with ocular MG, 77% of patients with predominantly bulbar fatigue, and in 83% of patients with predominantly limb fatigue.[ncbi.nlm.nih.gov]
  • Other common symptoms occurring out of fatiguability are slurred speech, diplopia or blurred vision, difficulty in chewing and dysphagia, weakness in arms and legs, chronic muscle fatigue, dyspnea, unstable gait, dysarthria i.e. difficulty in speaking[symptoma.com]
  • Central/bulbar involvement Test the power of head/neck flexion and extension (fatigue this movement as above) Ask the patient to take a deep breath and count out loud as many numbers as they can.[oxfordmedicaleducation.com]
  • Myasthenia gravis is a disorder of neuromuscular transmission that leads to fatigue of skeletal muscles and fluctuating weakness.[ncbi.nlm.nih.gov]
Chronic Fatigue Syndrome
  • Myalgic encephalomyelitis (ME) - 'chronic fatigue syndrome' - will have vague feelings of exhaustion made worse by any effort and no neurological signs to accompany it unless from disuse. The specific tests for MG will be negative.[patient.info]
Dysphagia
  • The subjects were classified into three groups; patients without dysphagia (group 1), patients with dysphagia (group 2), and healthy participants (group 3).[ncbi.nlm.nih.gov]
  • Although the presentation is typically observed with complaints of vision and bulbar symptoms such as diplopia, dystonia, and dysphagia, this article presents a case study of an elderly man with a history of increasing upper extremity weakness with complaints[ncbi.nlm.nih.gov]
  • Keywords: Autoimmunity; Dysphagia; Myasthenia Gravis 1. Introduction Dysphagia is a common symptom in Otolaryngology and there is an extensive differential diagnosis.[dx.doi.org]
  • Patients of MG usually present with bilateral ptosis, diplopia and fatigability, which may or may not coexist with generalised weakness, dysphagia and dysarthria. A46-year male presented with unilateral ptosis and diplopia.[ncbi.nlm.nih.gov]
  • A 37-year-old man with anti-muscle-specific tyrosine kinase (MuSK) antibody-positive myasthenia gravis (MG) presented with subacute progressive dysphagia and muscle weakness of the neck and bilateral upper extremities.[ncbi.nlm.nih.gov]
Choking
  • Swallowing, speaking and breathing If the weakness affects the muscles in the mouth, throat and chest, it can cause: difficulty chewing slurred speech a husky, quiet or nasal-sounding voice difficulty swallowing choking and accidentally inhaling bits[nhs.uk]
  • Myasthenia gravis symptoms can include: Breathing difficulties Fatigue Problems chewing and swallowing (choking) Facial muscle weakness or paralysis such as eyelid drooping Difficulty talking Difficulty climbing stairs A drooping head A common trait of[wakehealth.edu]
  • Problems with swallowing (choking and coughing frequently while eating) from throat muscle problems may lead to aspiration of food into the lungs, which will lead to pneumonia.[netwellness.org]
  • Difficulty breathing Difficulty chewing and swallowing Difficulty climbing stairs Difficulty talking Facial paralysis Difficulty lifting objects Hoarseness Difficulty standing from a seated position Muscle weakness that improves with rest Gagging or choking[bmc.org]
  • You may choke very easily, which makes it difficult to eat, drink or take pills. In some cases, liquids you're trying to swallow may come out your nose. Problems chewing.[mayoclinic.org]
Hypersalivation
  • Features suggestive of a cholinergic crisis (too much medication) include muscle fasciculation, pallor, sweating, hypersalivation and small pupils. If in doubt, perform an edrophonium test.[patient.info]
Ptosis
  • Medical management can have limitations in improving ptosis in patients with myasthenia gravis (MG). We present our experience of ptosis surgery in MG.[ncbi.nlm.nih.gov]
  • Except for unilateral moderate ptosis and restriction of extraocular movements, ocular and systemic examination was normal. Both ice pack and tensilon tests revealed improvement in ptosis.[ncbi.nlm.nih.gov]
  • Conventional ptosis crutches have limitations such as interference with blinking which causes ocular surface drying, and frequent irritation of the eyes.[ncbi.nlm.nih.gov]
  • The resulting sequence of daily selfies captured striking fluctuations in her ocular alignment and ptosis. Daily selfies may be a useful strategy for confirming the clinical diagnosis of ocular myasthenia gravis.[ncbi.nlm.nih.gov]
  • Patients with ocular myasthenia gravis can have disabling diplopia or functional blindness from ptosis and in most cases treatment is required.[ncbi.nlm.nih.gov]
Diplopia
  • Patients of MG usually present with bilateral ptosis, diplopia and fatigability, which may or may not coexist with generalised weakness, dysphagia and dysarthria. A46-year male presented with unilateral ptosis and diplopia.[ncbi.nlm.nih.gov]
  • A 69-year-old man, previously treated with pyridostigmine for myasthenia gravis (manifesting as ptosis and diplopia) was evaluated for several concomitant bilateral anterior orbital masses.[ncbi.nlm.nih.gov]
  • Risks of diplopia and exposure keratopathy should be discussed with the patient pre-operatively.[ncbi.nlm.nih.gov]
  • A 65-year-old man with advanced squamous cell lung carcinoma developed ptosis, diplopia, drop head, and general weakness 5 days after a third Nivo infusion.[ncbi.nlm.nih.gov]
  • Although the presentation is typically observed with complaints of vision and bulbar symptoms such as diplopia, dystonia, and dysphagia, this article presents a case study of an elderly man with a history of increasing upper extremity weakness with complaints[ncbi.nlm.nih.gov]
Strabismus
  • [J Pediatr Ophthalmol Strabismus. 2018;55(5):339-342.].[ncbi.nlm.nih.gov]
  • By contrast, control EOM from a patient undergoing strabismus surgery for a sensory exotropia in a nonseeing eye and a similar duration of deviation, showed normal muscle histology.[ncbi.nlm.nih.gov]
  • Children with myasthenia gravis require monitoring by a pediatric ophthalmologist for the development of amblyopia from ptosis or strabismus.[ncbi.nlm.nih.gov]
  • The ptosis and strabismus related to myasthenia can at times be helped with surgery; Surgical intervention is sometimes advised if the ptosis and/or strabismus deviation has been stable for at least one year.[aapos.org]
Blurred Vision
  • Case report A 63-year-old male presented with right eyelid drooping, puffiness, blurred vision, and shortness of breath two weeks after an initial infusion of pembrolizumab.[ncbi.nlm.nih.gov]
  • Other common symptoms occurring out of fatiguability are slurred speech, diplopia or blurred vision, difficulty in chewing and dysphagia, weakness in arms and legs, chronic muscle fatigue, dyspnea, unstable gait, dysarthria i.e. difficulty in speaking[symptoma.com]
  • Eye muscle weakness : most common initial symptom Ptosis Diplopia Blurred vision Bulbar muscle weakness Slurred speech, difficulty chewing and/or swallowing Proximal limb weakness Rising from a chair Climbing stairs Brushing hair Weakness of respiratory[amboss.com]
  • The disorder can affect any voluntary muscles, but specific muscle groups are frequently involved, including: Eye muscles - Effects include the drooping if one or both eyelids and double or blurred vision.[virginiamason.org]
  • Other common symptoms of this disease include: blurred vision difficulty chewing or swallowing inability to stand up without using hands unstable or unusual gait weakness in the arms, legs, hands, and fingers weakness in the muscles of facial expression[medbroadcast.com]
Unilateral Ptosis
  • A46-year male presented with unilateral ptosis and diplopia. Except for unilateral moderate ptosis and restriction of extraocular movements, ocular and systemic examination was normal. Both ice pack and tensilon tests revealed improvement in ptosis.[ncbi.nlm.nih.gov]
  • ., unilateral ptosis that remits and is followed a variable interval by ptosis of the other eye, is highly suggestive, as is diurnal fatigue of an extraocular muscle causing diplopia to develop and worsen as the day progresses.[myasthenia.puhs.org]
Muscle Weakness
  • Muscle weakness can involve any voluntary muscle.[ncbi.nlm.nih.gov]
  • Typically, extraocular muscle weakness is asymmetric and can be noticed easily.[symptoma.com]
  • Myasthenia gravis (MG) is a neuromuscular autoimmune disease characterized by skeletal muscle weakness which can impact motor function and, furthermore, produce negative impact on the health-related quality of life (HRQOL).[ncbi.nlm.nih.gov]
  • Dyspnea and muscle weakness improved gradually. Ipilimumab and nivolumab were permanently discontinued.[ncbi.nlm.nih.gov]
  • Myasthenia gravis is a chronic neuromuscular disorder that causes skeletal muscle weakness. Typically, myasthenia gravis affects the ocular, bulbar, neck, proximal limbs, and respiratory muscles.[ncbi.nlm.nih.gov]
Myopathy
  • We described four patients with both MG and inflammatory myopathy. These cases correspond to 2.3% of our MG cohort.[ncbi.nlm.nih.gov]
  • We review the relevant literature and discuss the hypothesis of a mitochondrial myopathy as a pathogenic mechanism in MuSK-antibody positive myasthenia gravis.[ncbi.nlm.nih.gov]
  • Hohlfeld R, Goebels N, Engel AG (1993) Cellular mechanisms in inflammatory myopathies. Baillieres Clin Neurol 2:617–635 PubMed 23. Jaretzki A, Steinglass KM, Sonett JR (2004) Thymectomy in the management of myasthenia gravis.[springermedizin.at]
  • For example, differential diagnoses for patients with ocular weakness may include thyroid ophthalmopathy, oculopharyngeal muscular dystrophy and mitochondrial myopathy.[clevelandclinicmeded.com]
  • […] polyneuropathies have been reported in patients with concurrent MG. [ 35 , 36] Various autoimmune channelopathies, autonomic neuropathy with and without encephalopathy concomitant with the MG and thymoma has also been reported. [ 37 ] MG and inflammatory myopathy[emedicine.medscape.com]
Proximal Muscle Weakness
  • This report presents a case-vignette of a 72-year-old woman with progressive proximal muscle weakness and myalgias, diagnosed with thymoma-associated myasthenia and bioptically verified granulomatous myositis, with positive autoantibody status for ryanodine[ncbi.nlm.nih.gov]
  • A 54-year-old gentleman presented with fluctuating ophthalmoplegia and proximal muscles weakness of 7 years duration that remitted with pyridostigmine and prednisolone.[ncbi.nlm.nih.gov]
  • Proximal muscle weakness is more often seen than distal muscle weakness. The anti-acetylcholine receptor antibody test is a very specific test which is done to diagnose myasthenia gravis.[symptoma.com]
  • Association : small-cell lung carcinoma (in ⅔ of LEMS cases) Clinical features Proximal muscle weakness Reduced or absent reflexes Autonomic symptoms Dry mouth Constipation Orthostatic dysregulation Diagnostics Physical examination Active muscle contraction[amboss.com]
  • The clinical features in LEMS include proximal muscle weakness and hyporeflexia with improvement of symptoms with repeated muscle stimulation . LEMS is caused by antibodies directed against presynaptic calcium channels.[eyewiki.aao.org]
Muscular Atrophy
Neck Weakness
  • weakness, a generally worse disease severity and a tendency to develop muscle atrophy.[ncbi.nlm.nih.gov]
Dysarthria
  • Patients of MG usually present with bilateral ptosis, diplopia and fatigability, which may or may not coexist with generalised weakness, dysphagia and dysarthria. A46-year male presented with unilateral ptosis and diplopia.[ncbi.nlm.nih.gov]
  • Six years later, he had a mild relapse of his PRCA and subsequently developed severe dysphagia and dysarthria which were fatigable. Positive antiacetylcholine receptor antibodies confirmed the diagnosis of myasthenia gravis.[ncbi.nlm.nih.gov]
  • We report the case of a 22-year-old man who presented with diplopia on lateral gaze to both sides, facial diplegia, nasal dysarthria and dysphagia.[ncbi.nlm.nih.gov]
  • She denied shortness of breath, dysarthria, and fatigue. She had been diagnosed with MG 6 years previously at the Neurology Department of our hospital.[ncbi.nlm.nih.gov]
  • After 3 months, the patient complained of increasing physical exhaustion, reduction of his walking distance, worsening of the residual dysphagia, and dysarthria with an inability to swallow.[ncbi.nlm.nih.gov]
Chronic Progressive External Ophthalmoplegia
  • Confirmatory test : serologic detection of antibodies directed against voltage-gated calcium channels Myasthenia gravis Chronic Progressive External Ophthalmoplegia ( CPEO ) Thyroid ophthalmopathy Ptosis Worsens throughout the day Often asymmetric Stays[amboss.com]
  • external ophthalmoplegia (CPEO), and developmental myopathy of the levator palpebrae superioris muscle.[eyewiki.aao.org]
  • See ocular dysmetria ; chronic progressive external ophthalmoplegia ; Cogan's lid twitch sign . my·as·the·ni·a gra·vis ( mīas-thēnē-ă grāvis ) [MIM*254200] Disorder of neuromuscular transmission marked by fluctuating weakness and fatigue of some voluntary[medical-dictionary.thefreedictionary.com]
Nasal Speech
  • Frequencies of other presenting symptoms are: leg weakness, 10%; fatigue, 9%; dysphagia, 6%; slurred or nasal speech, 5%; difficulty chewing, 4%; other weakness, 3%.[medicine.yale.edu]
  • With weakness of palatal muscles, nasal speech develops as air escapes through the nose. This may become increasingly apparent with prolonged speaking. Liquid may also escape through the nose during attempted swallowing with nasal regurgitation.[ojrd.biomedcentral.com]

Workup

The anti-acetylcholine receptor antibody test is a very specific test which is done to diagnose myasthenia gravis [7]. This is a very reliable test and is positive in almost 90% of the patients. Antistriated muscle antibody is another sensitive test to be diagnose myasthenia gravis. Muscle weakness should be tested for different parts of the body:

  • Looking upward and sideways for 30 seconds.
  • Walking 30 steps on both the toes or heels.
  • Keeping arms stretched for 60 seconds.

If any of the above tests is positive, i.e. there is fatigue at the end of the set time, it reveals that the patient is suffering from myasthenia gravis.

Single fiber electromyography might be performed [6] [8]. Repeated electrical impulses are given to the muscle fibers of the patient and electrodes are placed in to the muscle fiber to check for action potentials changes of the muscle fiber. This is a very specific test for myasthenia gravis and helps confirm the diagnosis.

Ice test: Application of ice will characteristically improve the weakness in the patients muscle and this is a very important non-invasive test to be performed. The basis of performing this test is that at lower temperatures acetylcholinesterase is inhibited, leaving more acetylcholine available at the junctions. Thus the patient can perform better as weakness is less [9].

Edrophonium test: Intravenous edrophonium bromide or tensilon will cause inhibition of breakdown of acetylcholine and thus improve weakness temporarily [10]. This test is usually performed only after all the other tests have failed to give an accurate result.

Radiography and CT scan or MRI will help confirm the diagnosis and show if a thymoma or any other tumor is leading to myasthenia gravis.

Anterior Mediastinal Mass
  • Video-assisted thoracoscopy is become a widely accepted approach for the resection of anterior mediastinal masses, including thymoma.[ncbi.nlm.nih.gov]
  • mediastinal mass Chest computed tomography is important to identify or rule out thymoma or thymic enlargement in all cases of MG In strictly ocular MG, magnetic resonance imaging of the brain and orbit is helpful to evaluate for mass lesions compressing[emedicine.medscape.com]
  • Chest CT is more sensitive than plain chest radiographs for delineating anterior mediastinal masses, and chest MRI does not improve diagnostic sensitivity.[ojrd.biomedcentral.com]
HLA-A1
  • In people 40 there is a higher incidence of HLA A1, B8, and DRW3 in patients with MG, and in those 40 there is a correlation with HLA A3, B7, and DRW2. In patients with thymoma there is no HLA association.[medicine.yale.edu]
  • The histocompatibility complex profile includes HLA-A1, -A3, -B7, -B8, -DRw3, and -DQw2 (though these have not been shown to be associated with the strictly ocular form of MG).[emedicine.medscape.com]
HLA-B8
  • This suggests an association of MG with HLA B8 and DR3. In terms of underlying genetic abnormalities, work is ongoing [ 8 ] . Presentation Almost all MG patients will have ocular manifestations at some point during the course of their disease.[patient.info]
  • The early peak shows a female predominance, approximately 3:1, and an association with HLA-B8, HLA-DR3, and HLA-DR1, the latter being more specific for ocular MG.[eyewiki.aao.org]
HLA-DR3
  • The early peak shows a female predominance, approximately 3:1, and an association with HLA-B8, HLA-DR3, and HLA-DR1, the latter being more specific for ocular MG.[eyewiki.aao.org]
HLA-A3
  • In people 40 there is a higher incidence of HLA A1, B8, and DRW3 in patients with MG, and in those 40 there is a correlation with HLA A3, B7, and DRW2. In patients with thymoma there is no HLA association.[medicine.yale.edu]

Treatment

Pharmacology includes medication and immunosuppressive agents like corticosteroids, cyclosporine, plasmapheresis and intravenous immunoglobulin. Thymectomy is another option for people who have thymoma.

Acetylcholineesterase inhibitors and immunomodulations are the most important modalities of treating patients with myasthenia gravis. They mostly prevent the acetylcholine from degrading and the weakness of the muscles thus reduces. This remains the initial line of treatment followed by corticosteroids as per need. Long term corticosteroids should be avoided as they may lead to further complications like osteoporosis, weight gain, diabetes etc.

Plasmapheresis is a procedure where the plasma is exchanged with fresh plasma which helps in removing out the circulating antibodies from the body. The new plasma contains lesser acetylcholine antibodies, reducing muscle weakness and fatiguability. This is short term relief for the patient especially if they undergo surgery. Exercise helps in a better prognosis.

Prognosis

The prognosis is good today as science has advanced a lot. Patients earlier had 3 to 4 % morbidity but now it has reduced further. Long term use of medications will give these patients a near normal life with very minimal complications. The only threat for these patients is the weakness affecting their respiratory muscles. This might lead to a need for supportive respiration i.e. ventilator support.

Etiology

Myasthenia gravis is an autoimmune disorder. It is the result of antibodies against the acetylcholinesterase receptors present at neuromuscular junctions which are responsible for muscular movements. These circulating antibodies cause weakness of the body by blocking acetylcholine receptors at the neuromuscular junctions.

Thymus gland abnormality is seen in 75% of the patients with myasthenia gavis. Very few patients may have a thymus tumor called as thymoma.

Certain drugs may induce myasthenia gravis e.g. Penicillamine, Antibiotics, lithium, Beta-adrenergic receptor blocking agents.

Epidemiology

Myasthenia gravis affects people of both the sexes but is more commonly seen in women of the age group 20 to 40 years. It also affects people who have thymus gland abnormalities. More commonly, it is seen in people who have other autoimmune disorders. The female to male ratio is 3:2 whereas in children the ratio is typically 5:1.

Sex distribution
Age distribution

Pathophysiology

Voluntary muscles of the body move by the excitatory impulses sent by nerves to the muscle through the neuromuscular junctions. In myasthenia gravis, the circulating antibodies block the receptors for acetylcholine at the neuromuscular junction leading to failure of transmission of efferent impulses to the muscle.

The acetylcholine receptor present in the motor end plate is called nicotinic acetylcholine receptor. Myasthenia gravis usually causes blocking or destruction of this receptor sites placed all over the body leading to weakness of varying degrees in voluntary muscles [2]. In a healthy person, the nerve carries impulses from the brain and passes on to the muscles through the neuromuscular junction where the neurotransmitter acetylcholine is released. This neurotransmitter then causes excitation of the receptor sites present on the muscular end of the junction.

In a myasthenia gravis patient, the nicotinic receptor sites are destroyed much faster than the body can repair and there is around 80% reduction in the receptor sites [3]. Even though acetylcholine is present, there aren’t enough receptor sites to bring about purposeful muscle movements.

Prevention

Myasthenia gravis might be prevented by avoiding ingestion of certain drugs which may cause this disease. However, it is essentially an autoimmune disorder and there is no exact way of preventing it.

Summary

Myasthenia gravis is an autoimmune disorder affecting the neuromuscular junctions between nerves and muscles affecting voluntary movements. It causes muscle weakness in varying proportions depending on the degree of affection.

It is also known as Goldflam disease and affects the voluntary group of muscles [1]. The term “Myasthenia gravis” literally originates from the Greek and Latin words which mean “grave muscular weakness.”

Patient Information

Myasthenia gravis is an autoimmune disorder which affects the neuromuscular junction (the junction where the nerve synapses meet the muscle fiber and transmits the impulse carried from the brain to the muscle). There are circulating antibodies that block the receptors for the neurotransmitter acetylcholine which are present at the junction and thereby do not allow the voluntary muscle to contract and produce movement.

This is a chronic disorder and gradually many of the receptor sites are destroyed leading to fatigability. There is drooping of eyelids on repeated eye strain, difficulty in swallowing or chewing, slurred or impaired speech, weakness of hands, fingers, legs. There may be weakness of head and difficulty in holding the head up straight. The weakness is least in the morning and keeps on increasing as the day progresses and the most important aspect of this weakness is that there is amelioration of weakness on rest.

This disease also affects children and neonates if the mother has the disease at the time of conception. Ice test, tensilon test and electromyography are the basic tests done for investigating this disease. Prognosis is good and patients are kept on long term acetylcholinesterase inhibitors, intravenous immunoglobulin and plasmapheresis.

References

Article

  1. ContiFine B, Milani M, Kaminski H et al. Myasthenia Gravis: past, present and future. J Clin Invest. 2006 Nov 1; 116(11):2843-54.
  2. Mc Grogan, Sneddon S, de Vries CS. The incidence of myasthenia gravis: a systematic literature review. Neuroepidemiology. 2010;34(3):171-83.
  3. Bedlack RS, Sanders DB. How to handle myasthenia crisis. Essential steps in patient care. Postgrad Med. 2004 Apr;107(4):211-4,220-2.
  4. Patrick J, Lindstrom J. Autoimmune response to acetylcholine receptor. Science. 1973 May 25;180(4088):871-2.
  5. Téllez-Zenteno JF, Hernández-Ronquillo L, Salinas V, Estanol B, et al. Myasthenia gravis and pregnancy: clinical implications and neonatal outcome. BMC Musculoskelet Disord. 2004 Nov 16;5:42.
  6. Selvan VA. Single-fiber EMG: A review. Ann Indian Acad Neurol.2011 Jan; 14(1): 64–67.
  7. Losen M, Stassen MH, Martínez-Martínez P, Machiels BM et al. Increased expression of rapsyn in muscles prevents acetylcholine receptor loss in experimental autoimmune myasthenia gravis. Brain. 2005 Oct; 128 (Pt 10): 2327–37.
  8. Juel VC. Myasthenia gravis: management of myasthenic crisis and perioperative care. Semin Neurol. 2004 Mar; 24 (1): 75–81.
  9. Cup EH, Pieterse AJ, Ten Broek-Pastoor JM, Munneke M, et al. Exercise therapy and other types of physical therapy for patients with neuromuscular diseases: a systematic review. Arch Phys Med Rehabil. 2007 Nov; 88 (11): 1452-64.
  10. Seybold ME. The office Tensilon test for ocular myasthenia gravis. Arch Neurol. 1986 Aug; 43 (8): 842–3.

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Last updated: 2018-06-22 06:48