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Myasthenia Gravis

By

Michael Rubin

, MDCM, New York Presbyterian Hospital-Cornell Medical Center

Last full review/revision Sep 2019| Content last modified Sep 2019
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Myasthenia gravis involves 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 sometimes IV edrophonium challenge, which briefly lessens the weakness. Treatment includes anticholinesterase drugs, immunosuppressants, corticosteroids, plasma exchange, IV immune globulin, and possibly thymectomy.

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 [RA], systemic lupus erythematosus [SLE], pernicious anemia).

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

  • Infection

  • Surgery

  • Certain drugs (eg, aminoglycosides, quinine, magnesium sulfate, procainamide, calcium channel blockers, immune checkpoint inhibitors)

Abnormal antibodies

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 forms

Ocular 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:

  • Reduced acetylcholine resynthesis due to choline acetyltransferase deficiency

  • End-plate acetylcholinesterase deficiency

  • Structural abnormalities in the postsynaptic receptor

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

The most common symptoms of myasthenia gravis are

  • Ptosis

  • Diplopia

  • Muscle weakness after use of the affected muscle

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 increased lacrimation and salivation, tachycardia, and diarrhea.

Diagnosis

  • Bedside tests

  • AChR antibody levels, electromyography, or both

The diagnosis of myasthenia gravis is suggested by symptoms and signs and confirmed by tests.

Bedside testing

The 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 electromyography

Even if a bedside test is unequivocally positive, one or both of the following are required to confirm the diagnosis:

  • Serum AChR antibody levels

  • Electromyography (EMG)

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 testing

Once 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, autoimmune hyperthyroidism, RA, SLE).

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

  • Anticholinesterase drugs to relieve symptoms

  • Corticosteroids, immunomodulating treatments (eg, IV immune globulin [IVIG], plasma exchange), immunosuppressants, or thymectomy to lessen the autoimmune reaction

  • Supportive care

In patients with congenital myasthenia, anticholinesterase drugs and immunomodulating treatments are not beneficial and should be avoided. Patients with respiratory failure require intubation and mechanical ventilation.

Symptomatic treatment

Anticholinesterase 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 treatment

Immunosuppressants interrupt the autoimmune reaction and slow the disease course, but they do not relieve symptoms rapidly. 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) 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 or IVIG is useful for myasthenic crisis and, for patients unresponsive to drugs, before thymectomy.

Key Points

  • Consider myasthenia gravis in patients with ptosis, diplopia, and muscle weakness after use of the affected muscle.

  • To confirm the diagnosis, measure serum levels of AChR antibody (usually present in myasthenia gravis), do electromyography (EMG), or both.

  • After the diagnosis is confirmed, test for thymic hyperplasia, thymomas, hyperthyroidism, and autoimmune disorders, which commonly accompany myasthenia gravis.

  • For most patients, use anticholinesterase drugs to relieve symptoms and immunomodulating treatment to slow disease progression and help relieve symptoms; do not use these treatments in patients with congenital myasthenia.

  • If patients suddenly deteriorate after responding well to treatment, provide respiratory support and stop anticholinesterase drugs for several days because they may have cholinergic crisis.

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