1
|
Vesperinas-Castro A, Cortés-Vicente E. Rituximab treatment in myasthenia gravis. Front Neurol 2023; 14:1275533. [PMID: 37849836 PMCID: PMC10577386 DOI: 10.3389/fneur.2023.1275533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/11/2023] [Indexed: 10/19/2023] Open
Abstract
Myasthenia gravis (MG) is a chronic autoimmune disease mediated by antibodies against post-synaptic proteins of the neuromuscular junction. Up to 10%-30% of patients are refractory to conventional treatments. For these patients, rituximab has been used off-label in the recent decades. Rituximab is a monoclonal antibody against the CD20 protein that leads to B cell depletion and to the synthesis of new antibody-secreting plasma cells. Although rituximab was created to treat B-cell lymphoma, its use has widely increased to treat autoimmune diseases. In MG, the benefit of rituximab treatment in MuSK-positive patients seems clear, but a high variability in the results of observational studies and even clinical trials has been reported for AChR-positive patients. Moreover, few evidence has been reported in seronegative MG and juvenile MG and some questions about regimen of administration or monitoring strategies, remains open. In this review, we intend to revise the available literature on this topic and resume the current evidence of effectiveness of Rituximab in MG, with special attention to results on every MG subtype, as well as the administration protocols, monitoring strategies and safety profile of the drug.
Collapse
Affiliation(s)
- Ana Vesperinas-Castro
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Cortés-Vicente
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
2
|
Spontaneous Remission in Juvenile Myasthenia Gravis: A cohort of 13 cases and review of the literature. Neuromuscul Disord 2022; 32:213-219. [DOI: 10.1016/j.nmd.2021.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022]
|
3
|
Myasthenia Gravis: Epidemiology, Pathophysiology and Clinical Manifestations. J Clin Med 2021; 10:jcm10112235. [PMID: 34064035 PMCID: PMC8196750 DOI: 10.3390/jcm10112235] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/17/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neurological disorder characterized by defective transmission at the neuromuscular junction. The incidence of the disease is 4.1 to 30 cases per million person-years, and the prevalence rate ranges from 150 to 200 cases per million. MG is considered a classic example of antibody-mediated autoimmune disease. Most patients with MG have autoantibodies against the acetylcholine receptors (AChRs). Less commonly identified autoantibodies include those targeted to muscle-specific kinase (MuSK), low-density lipoprotein receptor-related protein 4 (Lrp4), and agrin. These autoantibodies disrupt cholinergic transmission between nerve terminals and muscle fibers by causing downregulation, destruction, functional blocking of AChRs, or disrupting the clustering of AChRs in the postsynaptic membrane. The core clinical manifestation of MG is fatigable muscle weakness, which may affect ocular, bulbar, respiratory and limb muscles. Clinical manifestations vary according to the type of autoantibody, and whether a thymoma is present.
Collapse
|
4
|
O'Connell K, Ramdas S, Palace J. Management of Juvenile Myasthenia Gravis. Front Neurol 2020; 11:743. [PMID: 32793107 PMCID: PMC7393473 DOI: 10.3389/fneur.2020.00743] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/16/2020] [Indexed: 02/06/2023] Open
Abstract
Juvenile Myasthenia Gravis (JMG) is a rare disorder, defined as myasthenia gravis in children younger than 18 years of age. While clinical phenotypes are similar to adults, there are a number of caveats that influence management: broader differential diagnoses; higher rates of spontaneous remission; and the need to initiate appropriate treatment early, to avoid the long-term physical and psychosocial morbidity. Current practice is taken from treatment guidelines for adult MG or individual experience, with considerable variability seen across centers. We discuss our approach to treating JMG, in a large specialist JMG service, and review currently available evidence and highlight potential areas for future research. First-line treatment of generalized JMG is symptomatic management with pyridostigmine, but early use of immunosuppression, where good control is not achieved is important. Oral prednisolone is used as first-line immunosuppression with appropriate prevention and monitoring of side effects. Second-line therapies including azathioprine and mycophenolate may be considered where there is: no response to steroids, inability to wean to a reasonable minimum effective dose or if side-effects are intolerable. Management of ocular JMG is similar, but requires close involvement of ophthalmology in young children to prevent amblyopia. Muscle-specific tyrosine kinase (MuSK)-JMG show a poorer response to pyridostigmine and anecdotal evidence suggests that rituximab should be considered as second-line immunosuppression. Thymectomy is indicated in any patient with a thymoma, and consideration should be given in acetylcholine receptor (AChR) positive JMG allowing time for spontaneous remission. The benefit is less clear in ocular JMG and is not advised in MuSK-JMG. Children experiencing a myasthenic crisis require urgent hospital admission with access to the intensive care unit. PLEX is preferred over IVIG due to rapid onset of action, but this needs to be balanced with feasibility in very young children. Key questions remain in the management of JMG: when to initiate both first- and second-line treatments, choosing between steroid-sparing agents, and determining the optimal dose and treatment duration. We feel that given the rarity of this disease, the establishment of national registries and collaboration across groups will be needed to address these issues and facilitate future drug trials in JMG.
Collapse
Affiliation(s)
- Karen O'Connell
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Sithara Ramdas
- Department of Paediatric Neurology, John Radcliffe Hospital, Oxford, United Kingdom
| | - Jacqueline Palace
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
5
|
Krishna L, Abdul Jalil NF, Lott PW, Singh S, Choo MM. "Mummy, my eyelids are heavy": A case series of juvenile myasthenia gravis. Eur J Ophthalmol 2019; 31:NP119-NP122. [PMID: 31390886 DOI: 10.1177/1120672119867605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To report three cases of juvenile myasthenia gravis aged between 18 and 24 months with ocular symptoms as their first presentation. METHOD A case series. RESULTS We present a case series of juvenile myasthenia gravis in a tertiary centre in Malaysia. Two of the three cases consist of a pair of twins who presented with ptosis of bilateral eyes; the first twin presented 4 months later than the second twin. These two cases were positive for anti-acetylcholine receptor antibodies and had generalized myasthenia gravis, whereas the other case was negative for receptor antibodies and was purely ocular myasthenia gravis. CONCLUSION Juvenile myasthenia gravis is relatively rare in toddlers. Early diagnosis and commencement of treatment is important to slow the progression of the disease and avoiding life-threatening events.
Collapse
Affiliation(s)
- Logeswari Krishna
- Department Of Ophthalmology, University Malaya Eye Research Centre, University Of Malaya, Malaysia
| | | | - Pooi Wah Lott
- Department Of Ophthalmology, University Malaya Eye Research Centre, University Of Malaya, Malaysia
| | - Sujaya Singh
- Department Of Ophthalmology, University Malaya Eye Research Centre, University Of Malaya, Malaysia
| | - May May Choo
- Department Of Ophthalmology, University Malaya Eye Research Centre, University Of Malaya, Malaysia
| |
Collapse
|
6
|
Chou CC, Su IC, Chou IJ, Lin JJ, Lan SY, Wang YS, Kong SS, Chen YJ, Hsieh MY, Hung PC, Wang HS, Chou ML, Lin KL. Correlation of anti-acetylcholine receptor antibody levels and long-term outcomes of juvenile myasthenia gravis in Taiwan: a case control study. BMC Neurol 2019; 19:170. [PMID: 31319795 PMCID: PMC6637626 DOI: 10.1186/s12883-019-1397-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 07/08/2019] [Indexed: 12/19/2022] Open
Abstract
Background Myasthenia gravis is the most common disease affecting the neuromuscular junction. The most common etiology among patients with juvenile myasthenia gravis is the production of antibodies against the acetylcholine receptor. However, the clinical outcome in relation to serum levels of anti-acetylcholine receptor antibodies in juvenile myasthenia gravis has rarely been discussed. We aimed to analyze the correlation between the presence of anti-acetylcholine receptor antibodies and outcome in juvenile myasthenia gravis. Methods Patients diagnosed with juvenile myasthenia gravis younger than of 20 years of age were retrospectively recruited from January 1995 to February 2017 in a tertiary referral medical center. According to the Myasthenia Gravis Foundation of America outcome scale, the primary outcome was complete symptom remission and cessation of medications for at least 1 year measured 2 years after diagnosis. Secondary outcome was complete symptom remission at the last outpatient clinic. Results A total of 54 patients were followed up for over 2 years. Nine patients (9/54, 16.7%) achieved complete remission without medication use at 2 years after diagnosis. Thirteen (24.1%) patients achieved complete remission during longer follow-up periods. Those with negative anti-acetylcholine receptor antibodies were more likely to achieve complete remission at 2 years (6/15 [40%] vs. 3/39 [7.7%], 95% Confidence interval [CI] 1.670 to 38.323) and at the last outpatient clinic follow-up (8/15 [53.3%] vs. 5/39 [12.8%], 95% CI 2.367 to 20.704). Thirteen patients with comorbid autoimmune thyroid diseases were older than those without disease (11.8 ± 5.8 years old vs. 8.0 ± 6.3 years old, 95% CI 0.018 to 7.33). Moreover, patients negative for anti-acetylcholine receptor antibodies were less likely comorbid with autoimmune thyroid disease (1/35 [2.9%] vs. 12/71 [16.9%], 95% CI 0.018 to 1.161). Conclusions Juvenile myasthenia gravis patients without anti-acetylcholine antibodies exhibited significantly increased complete remission rates and a reduced likelihood of comorbid autoimmune thyroid diseases compared with those with anti-acetylcholine receptor antibodies among Chinese. Electronic supplementary material The online version of this article (10.1186/s12883-019-1397-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Cheng-Che Chou
- Division of Paediatrics, Keelung Chang Gung Memorial Hospital, 222, Maijin Road, Keelung, Taiwan
| | - I-Chen Su
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - I-Jun Chou
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Jainn-Jim Lin
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.,Division of Paediatrics, Neurocritical Care Centre, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shih-Yun Lan
- Division of Paediatrics, Saint Paul Hospital, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Yi-Shan Wang
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Shu-Sing Kong
- Division of Paediatrics, Taipei Medical University Shuang Ho Hospital, Zhonghe Dist., New Taipei City, Taiwan
| | - Yun-Ju Chen
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Meng-Ying Hsieh
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Po-Cheng Hung
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Huei-Shyong Wang
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan
| | - Min-Liang Chou
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.
| | - Kuang-Lin Lin
- Division of Paediatric Neurology, Chang Gung Memorial Hospital and Chang Gung Children's Hospital, Chang Gung University College of Medicine, 33305, No. 5, Fuxing St., Guishan Dist, Taoyuan, Taiwan.
| | | |
Collapse
|
7
|
Abstract
Myasthenia gravis is a disorder of neuromuscular transmission that leads to fatigue of skeletal muscles and fluctuating weakness. Myasthenia that affects children can be classified into the following 3 forms: transient neonatal myasthenia, congenital myasthenic syndromes, and juvenile myasthenia gravis (JMG). JMG is an autoimmune disorder that has a tendency to affect the extraocular muscles, but can also affect all skeletal muscles leading to generalized weakness and fatigability. Respiratory muscles may be involved leading to respiratory failure requiring ventilator support. Diagnosis should be suspected clinically, and confirmatory diagnostic testing be performed, including serum acetylcholine receptor antibodies, repetitive nerve stimulation, and electromyography. Treatment for JMG includes acetylcholinesterase inhibitors, immunosuppressive medications, plasma exchange, intravenous immunoglobulins, and thymectomy. Children with myasthenia gravis require monitoring by a pediatric ophthalmologist for the development of amblyopia from ptosis or strabismus.
Collapse
|
8
|
Lee HN, Kang HC, Lee JS, Kim HD, Shin HY, Kim SM, Sunwoo IN, Lee YM. Juvenile Myasthenia Gravis in Korea: Subgroup Analysis According to Sex and Onset Age. J Child Neurol 2016; 31:1561-1568. [PMID: 27581849 DOI: 10.1177/0883073816666206] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/16/2016] [Accepted: 07/28/2016] [Indexed: 11/16/2022]
Abstract
Juvenile myasthenia gravis presents before 18 years of age with different characteristics according to racial background and pubertal development. The authors aimed to determine the clinical characteristics of children and adolescents of Korean ethnicity with myasthenia gravis, and evaluate the presentation and clinical outcomes according to the sex and onset age of the patients. The authors recruited 88 Korean juvenile myasthenia gravis patients between September 2005 and August 2015. Worse clinical severity from presentation, more aggressive treatment strategies, and worse final treatment outcomes were noted in girls with postpubertal onset than in the other patients. The symptoms were milder (pure ocular presentation in 96.6% [85/88]) and the disease course was more benign (94.3% [83/88]) in this study than in the literature. The homogenous racial background might have contributed to these results. These findings highlight the influence of pubertal development and the need for timely and appropriate active treatment, including thymectomy, to improve prognosis.
Collapse
Affiliation(s)
- Ha Neul Lee
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hoon-Chul Kang
- Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Soo Lee
- Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Heung Dong Kim
- Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Min Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Il Nam Sunwoo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Mock Lee
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
9
|
Abstract
Juvenile myasthenia gravis is an uncommon autoimmune disorder. Its management is not standardized. Juvenile myasthenia gravis is pathophysiologically similar to myasthenia gravis in adults. However, a number of significant particularities related to race, age at onset, severity, and antibody status complicate the management. We summarize the unique clinical features of juvenile myasthenia gravis and review the therapeutic options.
Collapse
Affiliation(s)
- Cristian M Ionita
- Connecticut Children's Medical Center, Department of Pediatrics, and Division of Pediatric Neurology, Department of Neurology, University of Connecticut School of Medicine, Hartford, CT 06106, USA.
| | | |
Collapse
|
10
|
Nikolic DM, Nikolic AV, Lavrnic DV, Medjo BP, Ivanovski PI. Childhood-onset myasthenia gravis with thymoma. Pediatr Neurol 2012; 46:329-31. [PMID: 22520357 DOI: 10.1016/j.pediatrneurol.2012.02.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2011] [Accepted: 02/23/2012] [Indexed: 10/28/2022]
Abstract
Juvenile myasthenia gravis is an acquired, autoimmune disease occurring before age 16 years. Thymoma is exceedingly rare in children, especially in association with juvenile myasthenia gravis. We describe a 14-year-old boy with juvenile myasthenia gravis and thymoma. He presented with difficulties chewing and swallowing, nasal speech, and fluctuating weakness of the leg muscles. Neurologic examination revealed masticatory and bulbar muscle weakness with nasal speech, proximal muscle weakness, fatigability of the arms and legs, and distal muscle weakness of the legs. A diagnosis of juvenile myasthenia gravis was confirmed by a positive neostigmine test, a decremental response on repetitive nerve stimulation, and increased titers of serum anti-acetylcholine receptor antibodies. The patient received anticholinesterases, corticosteroids, azathioprine, and thymectomy. A pathohistologic analysis of the thymus gland indicated thymoma, Masaoka grade II. After 2 years of an unstable disease course, remission was achieved. Because only 10 cases of thymoma-associated myasthenia gravis are described in the pediatric population, this report offers an important contribution to a better understanding of this rare association.
Collapse
|
11
|
|
12
|
Abstract
PURPOSE OF REVIEW This review discusses recent studies on myasthenia gravis with onset in childhood (juvenile myasthenia gravis) and neonatal myasthenia gravis. RECENT FINDINGS The occurrence of myasthenia gravis in childhood is strongly influenced by genetic and environmental factors. Juvenile myasthenia gravis is associated with antibodies to the acetylcholine receptor (AChR) in most patients. Thymoma is rare, but often malignant in children. The frequency of juvenile myasthenia gravis with antibodies to the muscle-specific kinase (MuSK) varies markedly in different countries; some distinct features have been described. Management of juvenile myasthenia gravis does not differ, on the whole, from that of adult myasthenia gravis. Timing of thymectomy in young children is still controversial. Maternal antifetal type AChR antibodies can cause persistent focal weakness in the offspring, while neonatal myasthenia gravis associated with MuSK antibodies is often a severe and protracted albeit transient disease. SUMMARY Juvenile myasthenia gravis, like its adult-onset counterpart, is a heterogeneous disease. Clinical presentation is influenced by antibody status, ethnicity and age of onset. Treatment is very effective, but guidelines and controlled trials are needed.The risk for neonatal myasthenia gravis appears to be markedly influenced by maternal antibody subclass and antigen specificity. Adequate treatment in mothers can reduce both frequency and severity of neonatal disease.
Collapse
|
13
|
Bodack MI. Ptosis and cranial nerve IV palsy reveal juvenile myasthenia gravis. OPTOMETRY (ST. LOUIS, MO.) 2009; 80:342-349. [PMID: 19545846 DOI: 10.1016/j.optm.2008.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Revised: 02/19/2008] [Accepted: 03/04/2008] [Indexed: 05/28/2023]
Abstract
BACKGROUND Ptosis and strabismus are 2 common presenting complaints of preschool-age patients. In both cases, these conditions can be benign and require no further workup. However, sudden onset of these findings can indicate a more serious neurologic problem. If a patient presents with multiple neurologic signs, a sudden onset eye turn, or ptosis, the patient must undergo a workup to rule out a pathologic etiology, specifically a brain tumor. The workup should include neuroimaging. If the results of the neuroimaging are normal, and the findings are variable, myasthenia gravis should be considered, and additional testing should be ordered to assist in the diagnosis. CASE REPORT This case report presents a 3-year-old boy who presented with a sudden onset of ptosis and hypertropia. Diagnosis of myasthenia gravis was made based on clinical presentation and response to ice pack testing. The patient was treated with pyridostigmine (Mestinon; Valent Pharmaceuticals, Costa Mesa, California) and has shown improvement in his clinical signs. CONCLUSIONS Although rare, myasthenia should be considered a diagnosis in children who present with variable ptosis or strabismus. Patients can be successfully treated with medication.
Collapse
Affiliation(s)
- Marie I Bodack
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA.
| |
Collapse
|
14
|
Kostera-Pruszczyk A, Kwiecinski H. Juvenile seropositive myasthenia gravis with anti-MuSK antibody after thymectomy. J Neurol 2009; 256:1780-1. [DOI: 10.1007/s00415-009-5215-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 06/08/2009] [Accepted: 06/08/2009] [Indexed: 10/20/2022]
|
15
|
de la Calle Cabrera T, López Esteban P, Espínola Docio B, López Guinea A, García Teresa MA. [Juvenile myasthenia gravis. An overlooked disease by pediatricians]. An Pediatr (Barc) 2007; 66:422-3. [PMID: 17430725 DOI: 10.1157/13101253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|