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Nguyen M, Clough M, Cruse B, van der Walt A, Fielding J, White OB. Exploring Factors That Prolong the Diagnosis of Myasthenia Gravis. Neurol Clin Pract 2024; 14:e200244. [PMID: 38204589 PMCID: PMC10775161 DOI: 10.1212/cpj.0000000000200244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 12/05/2023] [Indexed: 01/12/2024]
Abstract
Background and Objectives Myasthenia gravis (MG) is a condition with significant phenotypic variability, posing a diagnostic challenge to many clinicians worldwide. Prolonged diagnosis can lead to reduced remission rates and morbidity. This study aimed to identify factors leading to a longer time to diagnosis in MG that could be addressed in future to optimize diagnosis time. Methods One hundred and ten patients from 3 institutions in Melbourne, Australia, were included in this retrospective cohort study. Demographic and clinical data were collected for these patients over the first 5 years from diagnosis and at 10 years. Nonparametric statistical analysis was used to identify factors contributing to a longer diagnosis time. Results The median time for MG diagnosis was 102 (345) days. 90% of patients were diagnosed before 1 year. Female patients took longer than male patients to be diagnosed (p = 0.013). The time taken for first presentation after symptom onset contributed most to diagnosis time (median 17 [141] days), with female patients and not working as contributory factors. Neurology referral took longer if patients had diplopia (p = 0.022), respiratory (p = 0.026) symptoms, or saw an ophthalmologist first (p < 0.001). Outpatient management compared with inpatient was associated with a longer time to be seen by a neurologist from referral (p < 0.001), for the first diagnostic result to return (p = 0.001), and for the result to be reviewed (p < 0.001). Ocular MG had a median greater time to neurologist review than generalized MG (median 5 [25] days vs 1 [13] days, p = 0.035). Electrophysiology tests took longer for outpatients than inpatients (median 21 [35] days vs 2 [8] days, p < 0.001). Outpatients were also started on treatment later than inpatients (p < 0.001). There was no association of MG severity, ethnicity, age, medical and ocular comorbidities, and public or private health service on diagnosis time. There was also no impact of time to diagnosis on Myasthenia Gravis Foundation of America outcomes, number of follow-ups or hospitalizations, or prevalence of treatments used. This study is limited by low patient numbers and its retrospective nature. Discussion This study identified several factors that can contribute to a prolonged diagnosis time of MG. Patient and clinician education about MG and outpatient diagnostic efficiency needs emphasis. Further studies are also needed to explore the delayed presentation time of women and nonworking patients in MG.
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Affiliation(s)
- Minh Nguyen
- Department of Neuroscience (MN, MC, AW, JF, OBW), Monash Health; Department of Neurology (BC), Royal Melbourne Hospital; and Department of Neurology (MN, AW), Alfred Health, Melbourne, Australia
| | - Meaghan Clough
- Department of Neuroscience (MN, MC, AW, JF, OBW), Monash Health; Department of Neurology (BC), Royal Melbourne Hospital; and Department of Neurology (MN, AW), Alfred Health, Melbourne, Australia
| | - Belinda Cruse
- Department of Neuroscience (MN, MC, AW, JF, OBW), Monash Health; Department of Neurology (BC), Royal Melbourne Hospital; and Department of Neurology (MN, AW), Alfred Health, Melbourne, Australia
| | - Anneke van der Walt
- Department of Neuroscience (MN, MC, AW, JF, OBW), Monash Health; Department of Neurology (BC), Royal Melbourne Hospital; and Department of Neurology (MN, AW), Alfred Health, Melbourne, Australia
| | - Joanne Fielding
- Department of Neuroscience (MN, MC, AW, JF, OBW), Monash Health; Department of Neurology (BC), Royal Melbourne Hospital; and Department of Neurology (MN, AW), Alfred Health, Melbourne, Australia
| | - Owen B White
- Department of Neuroscience (MN, MC, AW, JF, OBW), Monash Health; Department of Neurology (BC), Royal Melbourne Hospital; and Department of Neurology (MN, AW), Alfred Health, Melbourne, Australia
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Sergeeva MS, Danilov SS, Sherbakova NI. [Ocular myasthenia gravis]. Vestn Oftalmol 2024; 140:86-91. [PMID: 39254395 DOI: 10.17116/oftalma202414004186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Myasthenia gravis is an autoimmune disease characterized by muscle weakness and pathological fatigue due to autoaggressive phenomena with the formation of antibodies directed against various structures of the neuromuscular synapse. In most patients, the disease begins with the involvement of extraocular muscles, presenting with symptoms such as intermittent ptosis of the upper eyelid and/or binocular diplopia. In 15% of cases, clinical manifestations are limited to impairment of the levator palpebrae superioris and extraocular muscles, characteristic of the ocular form of myasthenia gravis. Specialists often encounter challenges in diagnosing this form, as serological and electrophysiological studies may be uninformative, necessitating diagnosis based on patient history and clinical picture. This literature review outlines the key aspects of the pathogenesis, clinical manifestations, methods of diagnosis and treatment of ocular myasthenia gravis.
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Affiliation(s)
- M S Sergeeva
- Krasnov Research Institute of Eye Diseases, Moscow, Russia
| | - S S Danilov
- Krasnov Research Institute of Eye Diseases, Moscow, Russia
| | - N I Sherbakova
- P. Hertsen Moscow Oncology Research Institute - branch of the National Medical Research Radiological Centre, Russia, Moscow
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Proudman W, Kleinig O, Lam L, Collins L, Bagster M, Gupta A, Kovoor J, Bacchi S, Slee M, Chan W. The Icepack Test in the Diagnosis of Myasthenia Gravis with Ocular Features: A Systematic Review of Diagnostic Accuracy, Technique, and Economic Utility. Semin Ophthalmol 2023; 38:679-685. [PMID: 36967601 DOI: 10.1080/08820538.2023.2194984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The diagnosis of myasthenia gravis (MG) may be challenging and require multiple specialised testing modalities. Accessing these investigations can involve significant waiting time and costs. The bedside icepack test (IPT) has been proposed to assist with the diagnosis of MG with ocular features, and may prove an economically viable; however, there have been there is heterogeneity in the literature evaluating the IPT. OBJECTIVES A systematic review was performed examining the accuracy, described techniques, and economic implications of the IPT for the diagnosis of MG with ocular features. METHOD The databases EMBASE, PubMed, and the Cochrane Library were searched from inception to July 2022. The systematic review adhered to PRISMA guidelines. Eligibility determination was undertaken with a standardised form using appropriate inclusion criteria. The Cochrane risk of bias assessment tool for diagnostic test accuracy was employed to evaluate studies that presented the diagnostic performance of the IPT. The Johanna Briggs Institute Critical Appraisal Checklist for Economic Evaluations was used for the assessment of studies presenting economic evaluations of the IPT. RESULTS 20 articles met the specified criteria and included a total of 1264 participants. The IPT had a sensitivity ranging from 38.5% to 100%. Specificity was found to be > 95% in six studies. Excluding two outlier results of 25% and 31.3%, the lowest specificity recorded was 62.5%. The most commonly described method of evaluating the IPT involved applying ice to both eyelids and using a >2 mm change as a threshold for a positive test (evaluated with a ruler). There were no adverse effects described with the IPT. There were no studies that formally examined the economic implications of the IPT. CONCLUSIONS The IPT is a well-tolerated and readily available diagnostic tool that has an important role in the evaluation of possible MG with ocular features in specific contexts. Despite limited economic evaluation of this test, it is likely the use of the IPT may result in significant financial and time savings.
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Affiliation(s)
| | | | - Lydia Lam
- University of Adelaide, Adelaide, SA, Australia
| | - Luke Collins
- Flinders Medical Centre, Bedford Park, SA, Australia
| | | | - Aashray Gupta
- Gold Coast University Hospital, Southport, Australia
| | - Joshua Kovoor
- University of Adelaide, Adelaide, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Stephen Bacchi
- University of Adelaide, Adelaide, SA, Australia
- Flinders Medical Centre, Bedford Park, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mark Slee
- Flinders Medical Centre, Bedford Park, SA, Australia
| | - WengOnn Chan
- University of Adelaide, Adelaide, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
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Meiler SE, Siwemuke TJ, Postma GN. New-Onset Myasthenia Gravis Mimics Spinal Cord Injury After Zenker's Diverticulum Repair. OTO Open 2023; 7:e56. [PMID: 37305099 PMCID: PMC10248725 DOI: 10.1002/oto2.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/13/2023] [Indexed: 06/13/2023] Open
Affiliation(s)
- Steffen E. Meiler
- Department of Anesthesiology and Perioperative Medicine, Medical College of GeorgiaAugusta UniversityAugustaGeorgiaUSA
| | | | - Gregory N. Postma
- Department of Otolaryngology, Medical College of GeorgiaAugusta UniversityAugustaGeorgiaUSA
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Buechner S, Capone L. Ice Pack Test Eased Ptosis in a Patient Presenting with a Possible Oculomotor Nerve Schwannoma: A Case Report. Neurol Int 2021; 13:510-516. [PMID: 34698277 PMCID: PMC8544292 DOI: 10.3390/neurolint13040050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/15/2021] [Accepted: 09/10/2021] [Indexed: 11/21/2022] Open
Abstract
A 32-year-old man presented with complete third nerve palsy. Brain magnetic resonance imaging revealed a possible sporadic oculomotor nerve schwannoma in the left cavernous sinus. Interestingly, the patient’s ptosis was fluctuating and eased immediately after application of ice over his eyelid. The ice pack test (IPT) is a simple and fast method that can help diagnose myasthenia gravis (MG) in patients with ptosis. Additional diagnostic investigations (antibody assays and repetitive stimulation) excluded associated MG in the patient. Tumor treatment with Gamma Knife radiosurgery was planned. This case highlights the finding that IPT can also be positive in neurogenic (non-myasthenic) ptosis, but its usefulness in other disorders associated with muscle weakness and fatigability remains questionable.
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Silvestri N. Reader Response: Comparison of Ice Pack Test and Single-Fiber EMG Diagnostic Accuracy in Patients Referred for Myasthenic Ptosis. Neurology 2021; 96:918. [PMID: 34032602 DOI: 10.1212/wnl.0000000000011901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Evoli A, Iorio R. Controversies in Ocular Myasthenia Gravis. Front Neurol 2020; 11:605902. [PMID: 33329368 PMCID: PMC7734350 DOI: 10.3389/fneur.2020.605902] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
Myasthenia gravis (MG) with symptoms limited to eye muscles [ocular MG (OMG)] is a rare disease. OMG incidence varies according to ethnicity and age of onset. In recent years, both an increase in incidence rate, particularly in the elderly, and a lower risk for secondary generalization may have contributed to the growing disease prevalence in Western countries. OMG should be considered in patients with painless ptosis and extrinsic ophthalmoparesis. Though asymmetric muscle involvement and symptom fluctuations are typical, in some cases, OMG can mimic isolated cranial nerve paresis, internuclear ophthalmoplegia, and conjugate gaze palsy. Diagnostic confirmation can be challenging in patients negative for anti-acetylcholine receptor and anti-muscle-specific tyrosine kinase antibodies on standard radioimmunoassay. Early treatment is aimed at relieving symptoms and at preventing disease progression to generalized MG. Despite the absence of high-level evidence, there is general agreement on the efficacy of steroids at low to moderate dosage; immunosuppressants are considered when steroid high maintenance doses are required. The role of thymectomy in non-thymoma patients is controversial. Prolonged exposure to immunosuppressive therapy has a negative impact on the health-related quality of life in a proportion of these patients. OMG is currently excluded from most of the treatments recently developed in generalized MG.
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Affiliation(s)
- Amelia Evoli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raffaele Iorio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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Doughty CT, Guidon AC. Diagnostic testing for ocular myasthenia gravis: Stronger together. Neurology 2020; 95:563-564. [PMID: 32788244 DOI: 10.1212/wnl.0000000000010616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Christopher T Doughty
- From Brigham and Women's Hospital (C.T.D.); Harvard Medical School (C.T.D., A.C.G.); and Massachusetts General Hospital (A.C.G.), Boston.
| | - Amanda C Guidon
- From Brigham and Women's Hospital (C.T.D.); Harvard Medical School (C.T.D., A.C.G.); and Massachusetts General Hospital (A.C.G.), Boston
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Giannoccaro MP, Paolucci M, Zenesini C, Di Stasi V, Donadio V, Avoni P, Liguori R. Comparison of ice pack test and single-fiber EMG diagnostic accuracy in patients referred for myasthenic ptosis. Neurology 2020; 95:e1800-e1806. [PMID: 32788239 DOI: 10.1212/wnl.0000000000010619] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/14/2020] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To compare the diagnostic accuracy of ice pack test (IPT) and single-fiber EMG (SF-EMG) in patients with suspected ocular myasthenia (OM) presenting with ptosis. METHODS We studied consecutive patients referred for the clinical suspicion of OM. Patients underwent IPT and stimulated SF-EMG on the orbicularis oculi muscle. Receiver operating characteristic curve analysis was performed to determine the accuracy of IPT, SF-EMG, and their combination. RESULTS We included 155 patients, 102 with OM and 53 with other diagnosis (OD). The IPT had a sensitivity of 86% (95% confidence interval [CI] 79-93) and a specificity of 79% (95% CI 68-90). SF-EMG showed a sensitivity of 94% (95% CI 89-98) and a specificity of 79% (95% CI 68-90). Overall, IPT and SF-EMG showed discordant results in 30 cases, 16 OM and 14 OD. The combination of IPT and SF-EMG, using the positivity of at least one test for OM diagnosis, increased the sensitivity to 98% (95% CI 95-100), reducing the specificity to 66% (95% CI 53-78), whereas using the positivity of both tests, we obtained a sensitivity of 82% (95% CI 75-90) and a specificity of 92% (95% CI 85-99). The negativity of both tests had a 94% (95% CI 87-100) negative predictive value. Comparison of the areas under the curve showed no differences in the diagnostic accuracy of IPT, SF-EMG, and their combinations. CONCLUSIONS IPT and SF-EMG have similar diagnostic accuracy in patients with OM presenting with ptosis. The negativity of both tests strongly suggests another diagnosis. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that both the IPT and SF-EMG accurately identify patients with OM.
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Affiliation(s)
- Maria Pia Giannoccaro
- From the Dipartimento di Scienze Biomediche e Neuromotorie (M.P.G., P.A., R.L.), Università di Bologna; IRCCS Istituto delle Scienze Neurologiche di Bologna (M.P.G., C.Z., V.D.S., V.D., P.A., R.L.); UO Neurosonologia e Cefalee (M.P.), Università Campus Bio-Medico, Rome; and UO Neurologia (M.P.), Ospedale M. Bufalini, Cesena, AUSL Romagna, Italy.
| | - Matteo Paolucci
- From the Dipartimento di Scienze Biomediche e Neuromotorie (M.P.G., P.A., R.L.), Università di Bologna; IRCCS Istituto delle Scienze Neurologiche di Bologna (M.P.G., C.Z., V.D.S., V.D., P.A., R.L.); UO Neurosonologia e Cefalee (M.P.), Università Campus Bio-Medico, Rome; and UO Neurologia (M.P.), Ospedale M. Bufalini, Cesena, AUSL Romagna, Italy
| | - Corrado Zenesini
- From the Dipartimento di Scienze Biomediche e Neuromotorie (M.P.G., P.A., R.L.), Università di Bologna; IRCCS Istituto delle Scienze Neurologiche di Bologna (M.P.G., C.Z., V.D.S., V.D., P.A., R.L.); UO Neurosonologia e Cefalee (M.P.), Università Campus Bio-Medico, Rome; and UO Neurologia (M.P.), Ospedale M. Bufalini, Cesena, AUSL Romagna, Italy
| | - Vitantonio Di Stasi
- From the Dipartimento di Scienze Biomediche e Neuromotorie (M.P.G., P.A., R.L.), Università di Bologna; IRCCS Istituto delle Scienze Neurologiche di Bologna (M.P.G., C.Z., V.D.S., V.D., P.A., R.L.); UO Neurosonologia e Cefalee (M.P.), Università Campus Bio-Medico, Rome; and UO Neurologia (M.P.), Ospedale M. Bufalini, Cesena, AUSL Romagna, Italy
| | - Vincenzo Donadio
- From the Dipartimento di Scienze Biomediche e Neuromotorie (M.P.G., P.A., R.L.), Università di Bologna; IRCCS Istituto delle Scienze Neurologiche di Bologna (M.P.G., C.Z., V.D.S., V.D., P.A., R.L.); UO Neurosonologia e Cefalee (M.P.), Università Campus Bio-Medico, Rome; and UO Neurologia (M.P.), Ospedale M. Bufalini, Cesena, AUSL Romagna, Italy
| | - Patrizia Avoni
- From the Dipartimento di Scienze Biomediche e Neuromotorie (M.P.G., P.A., R.L.), Università di Bologna; IRCCS Istituto delle Scienze Neurologiche di Bologna (M.P.G., C.Z., V.D.S., V.D., P.A., R.L.); UO Neurosonologia e Cefalee (M.P.), Università Campus Bio-Medico, Rome; and UO Neurologia (M.P.), Ospedale M. Bufalini, Cesena, AUSL Romagna, Italy
| | - Rocco Liguori
- From the Dipartimento di Scienze Biomediche e Neuromotorie (M.P.G., P.A., R.L.), Università di Bologna; IRCCS Istituto delle Scienze Neurologiche di Bologna (M.P.G., C.Z., V.D.S., V.D., P.A., R.L.); UO Neurosonologia e Cefalee (M.P.), Università Campus Bio-Medico, Rome; and UO Neurologia (M.P.), Ospedale M. Bufalini, Cesena, AUSL Romagna, Italy
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Abstract
PURPOSE OF REVIEW Myasthenia gravis (MG) is an autoimmune neuromuscular disease that causes fluctuating weakness in ocular, bulbar, and limb muscles and can, in 15% of cases, cause myasthenic crisis, a neurologic emergency characterized by respiratory failure. Although infrequent, MG needs to be promptly recognized and treated because the potential for improvement and remission is very high. The diagnosis of MG can be challenging and delayed because of the fluctuating nature of muscle weakness and the overlap of signs and symptoms with other neuromuscular diseases.This article reviews the importance of prompt recognition of the typical signs and symptoms, best tests to confirm the diagnosis, currently available acute and chronic treatment modalities, the role of thymectomy, and the natural history of the disease. Special consideration related to the diagnosis and management in women during pregnancy and in children will also be reviewed. This article also includes an overview of congenital myasthenic syndromes. RECENT FINDINGS Recent significant efforts in standardizing and improving the care of patients with MG have occurred, as well as new momentum in developing new drugs for patients with MG who do not adequately respond to currently available treatments. The number of clinical trials and drugs in development for MG is steadily increasing. Eculizumab has been recently approved by the US Food and Drug Administration (FDA) for adult patients with generalized MG who are acetylcholine receptor-antibody positive, based on the REGAIN (Safety and Efficacy of Eculizumab in Refractory Generalized Myasthenia Gravis) study, a phase 3, randomized, double-blind, placebo-controlled, multicenter trial. An international, multicenter, randomized trial comparing thymectomy plus prednisone with prednisone alone has demonstrated that thymectomy improves clinical outcome in patients with nonthymomatous MG. Clinical care guidelines have been published, and the recommendations for clinical research standards and the Myasthenia Gravis Foundation of America MGFA clinical classification published in 2000 have become widely accepted by the clinical and research community of MG experts. SUMMARY MG is a highly treatable disease with many effective treatment modalities available and with a natural history that continues to improve thanks to better diagnostic tests and effective drugs. The diagnosis and management of patients affected by MG can be highly rewarding for any neurologist as most patients are able to live normal lives if treated appropriately. Nevertheless, future research is needed to address unresolved clinical issues, such as when and how to discontinue immunosuppressive medications in patients in remission, the role and timing of thymectomy in children, and better treatment options for refractory patients.
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Klein S, Feldman R, Chhabra N. The Bedside Ice Pack Test for Myasthenia Gravis. J Emerg Med 2019; 58:334-335. [PMID: 31796223 DOI: 10.1016/j.jemermed.2019.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/23/2019] [Accepted: 10/13/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Samuel Klein
- Department of Emergency Medicine, Cook County Health and Hospitals System, Chicago, Illinois
| | - Robert Feldman
- Department of Emergency Medicine, Cook County Health and Hospitals System, Chicago, Illinois
| | - Neeraj Chhabra
- Department of Emergency Medicine, Cook County Health and Hospitals System, Chicago, Illinois
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Kee HJ, Yang HK, Hwang JM, Park KS. Evaluation and validation of sustained upgaze combined with the ice-pack test for ocular myasthenia gravis in Asians. Neuromuscul Disord 2019; 29:296-301. [DOI: 10.1016/j.nmd.2018.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/28/2018] [Accepted: 12/18/2018] [Indexed: 11/29/2022]
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A Neurologist's Perspective on Understanding Myasthenia Gravis: Clinical Perspectives of Etiologic Factors, Diagnosis, and Preoperative Treatment. Thorac Surg Clin 2019; 29:133-141. [PMID: 30927994 DOI: 10.1016/j.thorsurg.2018.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Myasthenia gravis (MG) is a disease of neuromuscular transmission caused by antibodies directed toward proteins concentrated at the neuromuscular junction. Mild to life-threatening weakness varies in severity over time and with level of activity. Therefore, clinical diagnosis is often challenging. MG may be categorized by autoantibody type, thymic pathologic condition, and age of onset. Treatments are tailored for each group. A key management concern is severe exacerbation of weakness resulting from infections or exposure to certain medications, including antibiotics, which may be severe enough to produce respiratory decompensation. The article reviews key diagnostic issues and treatment options.
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Italian recommendations for the diagnosis and treatment of myasthenia gravis. Neurol Sci 2019; 40:1111-1124. [PMID: 30778878 DOI: 10.1007/s10072-019-03746-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/31/2019] [Indexed: 12/30/2022]
Abstract
Myasthenia gravis is a well-treatable disease, in which a prompt diagnosis and an adequate management can achieve satisfactory control of symptoms in the great majority of patients. Improved knowledge of the disease pathogenesis has led to recognition of patient subgroups, according to associated antibodies, age at onset and thymus pathology, and to a more personalized treatment. When myasthenia gravis is suspected on clinical grounds, diagnostic confirmation relies mainly on the detection of specific antibodies. Neurophysiological studies and, to a lesser extent, clinical response to cholinesterase inhibitors support the diagnosis in seronegative patients. In these cases, the differentiation from congenital myasthenia can be challenging. Treatment planning must consider weakness extension and severity, disease subtype, thymus pathology, together with patient characteristics and comorbidities. Since most subjects with myasthenia gravis require long-term immunosuppressive therapy, surveillance of expected and potential adverse events is critical. For patients refractory to conventional immunosuppression, the use of biologic agents is highly promising. These recommendations are addressed to non-experts on neuromuscular transmission disorders. The diagnostic procedures and therapeutic approaches hereafter described are largely accessible in Italy.
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Abstract
PURPOSE OF REVIEW Myasthenia gravis is an autoimmune disease that commonly affects the palpebral and extraocular muscles. Ocular myasthenia gravis (OMG) is a variant of the disease that is confined to the ocular muscles but frequently becomes generalized over time. The diagnosis of OMG is often challenging but both clinical and laboratory findings are helpful in confirming the clinical suspicion. This review provides an update on the diagnostic approach and therapeutic options for OMG. RECENT FINDINGS Antimuscle-specific tyrosine kinase and LDL-related receptor-related protein 4 are newly available serologic testing for myasthenia gravis that can help in increasing the diagnostic sensitivity of OMG. They should be included to the diagnostic algorithm of OMG in appropriate clinical situations. SUMMARY OMG remains a primarily clinical diagnosis, but recent advances in laboratory testing can improve the diagnostic accuracy and should be used in appropriate clinical settings. The mainstay of treatment for OMG has not significantly changed over the past years, but the increasing availability of steroid-sparing agents improved the disease control while minimizing steroid-induced complications.
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Alvarez CN, John RM. The Pediatric Primary Care Management of Myasthenia Gravis. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2018.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Sudden Bilateral Ptosis in a 61-Year-Old Woman. J Neuroophthalmol 2018; 38:375-378. [DOI: 10.1097/wno.0000000000000701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Roper J, Fleming ME, Long B, Koyfman A. Myasthenia Gravis and Crisis: Evaluation and Management in the Emergency Department. J Emerg Med 2017; 53:843-853. [PMID: 28916122 DOI: 10.1016/j.jemermed.2017.06.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 06/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Myasthenia gravis (MG) is an uncommon autoimmune disorder affecting the neuromuscular junction and manifesting as muscle weakness. A multitude of stressors can exacerbate MG. When symptoms are exacerbated, muscle weakness can be severe enough to result in respiratory failure, a condition known as myasthenic crisis (MC). OBJECTIVE This review discusses risk factors, diagnosis, management, and iatrogenic avoidance of MC. DISCUSSION MC can affect any age, ethnicity, or sex and can be precipitated with any stressor, infection being the most common. MC is a clinical diagnosis defined by respiratory failure caused by exacerbation of MG. Muscle weakness can involve any voluntary muscle. MC can be differentiated from other neuromuscular junction diseases by the presence of normal reflexes, normal sensation, lack of autonomic symptoms, lack of fasciculations, and worsening weakness with repetitive motion. Treatment should target the inciting event and airway support. All acetylcholinesterase inhibitors should be avoided in crisis, including edrophonium testing and corticosteroids initially. Respiratory support can begin with noninvasive positive-pressure ventilation, as this has been successful even in patients with bulbar weakness. If intubation is necessary, consider avoiding paralytics or use a reduced dose of nondepolarizing agents. CONCLUSIONS MC should be in the differential of any patient with muscular weakness and respiratory compromise. Emergency department management of MC should focus on ruling out infection and respiratory support. Strong consideration should be given to beginning with noninvasive positive-pressure ventilation for ventilatory support. Corticosteroids, depolarizing paralytics, and acetylcholinesterase inhibitors should be avoided in patients with MC in the emergency department.
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Affiliation(s)
- Jamie Roper
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - M Emily Fleming
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Seo EJ, Park A, Chung SA. Two Cases with Positive Ice Tests Mimicking Ocular Myasthenia Gravis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2015. [DOI: 10.3341/jkos.2015.56.2.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Eoi Jong Seo
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
| | - Aram Park
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
| | - Seung Ah Chung
- Department of Ophthalmology, Ajou University School of Medicine, Suwon, Korea
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21
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Mohamed Yousuf UA, Yashodhara BM, Thanigasalam T, Ting HS. "Why do I always see double?" A misdiagnosed case of ocular myasthenia gravis for 10 years. BMJ Case Rep 2014; 2014:bcr2013203488. [PMID: 24792021 PMCID: PMC4024570 DOI: 10.1136/bcr-2013-203488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2014] [Indexed: 11/03/2022] Open
Abstract
A 58-year-old man presented with diplopia and partial ptosis for 10 years. It was non-progressive in nature, despite inadequate medical attention the patient received from non-specialists/general practitioners. He did not have fatigability or diurnal variation in weakness and was clinically stable without exacerbations of disease for a decade. He did not have features of Graves's disease, oculopharyngeal dystrophy, cranial nerve paralysis, polymyositis and stroke. The possibility of an atypical presentation of myasthenia gravis (MG) was considered and the patient was evaluated. Ice pack test was negative, Cogan's lid twitch (CLT) test was positive and high titres of acetylcholine receptor antibodies (AChR Ab) suggestive of MG were found. He was treated accordingly with a very good response.
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Affiliation(s)
| | - B M Yashodhara
- Department of Medicine, Melaka Manipal Medical College, Melaka, Malaysia
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