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Gabbard R, Yi R, Pratt J, Chang K, Keck K. Juvenile ocular myasthenia gravis: a report of two cases. Digit J Ophthalmol 2024; 30:15-18. [PMID: 38601901 PMCID: PMC11001568 DOI: 10.5693/djo.02.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
We report 2 cases of pediatric ocular myasthenia gravis. The first case was a 7-year-old girl who presented with bilateral ophthalmoplegia and ptosis that correlated with the onset of upper respiratory symptoms. Neuroimaging and acetylcholine receptor antibody testing were unremarkable. The ice pack test was positive. Symptoms greatly improved with pyridostigmine, with full resolution of ophthalmoplegia achieved by 8-month follow-up. The second case was a 4-year-old girl who presented emergently with ptosis and bilateral ophthalmoplegia. Acetylcholine receptor antibodies testing was positive. The patient was started on pyridostigmine and intravenous immunoglobulin and is scheduled to follow-up with pediatric ophthalmology in the outpatient setting.
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Affiliation(s)
- Ryan Gabbard
- University of South Carolina / Prisma Health, Columbia, South Carolina
| | - Richard Yi
- University of South Carolina / Prisma Health, Columbia, South Carolina
| | - James Pratt
- University of South Carolina School of Medicine, Columbia, South Carolina
| | - Kenneth Chang
- University of South Carolina / Prisma Health, Columbia, South Carolina
| | - Katie Keck
- University of South Carolina / Prisma Health, Columbia, South Carolina
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2
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Pietris J, Madike R, Lam A, Al Sharifi A, Bacchi S, Gupta AK, Kovoor JG, Chan W. Cogan's Lid Twitch for Myasthenia Gravis: A Systematic Review. Semin Ophthalmol 2023; 38:727-736. [PMID: 37166275 DOI: 10.1080/08820538.2023.2211134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/12/2023]
Abstract
INTRODUCTION Myasthenia gravis is an autoimmune condition affecting the neuromuscular junction of skeletal muscles and may be difficult to diagnose. Several clinical signs may have diagnostic utility, including Cogan's lid twitch. This systematic review aims to synthesise the literature on the accuracy of Cogan's lid twitch for diagnosing myasthenia gravis. METHODS A systematic search of the databases PubMed/MEDLINE, Embase and CENTRAL was performed from inception to August 2022. Risk of bias analysis and data extraction were performed in accordance with the PRISMA 2020 guidelines. RESULTS Seven articles satisfied the inclusion criteria. The results showed that for the diagnosis of myasthenia gravis, Cogan's lid twitch has a sensitivity between 50% and 99% and specificity between 75% and 100%. CONCLUSIONS Cogan's lid twitch is a physical examination finding with moderate diagnostic performance in the diagnosis of myasthenia gravis with ocular involvement. Future studies may seek to evaluate the performance of Cogan's lid twitch in conjunction with other signs of myasthenia gravis with ocular involvements, such as fatigable ptosis or a positive icepack test.
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Affiliation(s)
- James Pietris
- Faculty of Medicine, University of Queensland, Herston, Australia
- Princess Alexandra Hospital, Woolloongabba, Australia
| | - Reema Madike
- Faculty of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Antoinette Lam
- Faculty of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Ali Al Sharifi
- Faculty of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Stephen Bacchi
- Faculty of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Aashray K Gupta
- Faculty of Medicine, University of Adelaide, Adelaide, SA, Australia
- Gold Coast University Hospital, Southport, Australia
| | - Joshua G Kovoor
- Faculty of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - WengOnn Chan
- Faculty of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Ophthalmology, Royal Adelaide Hospital, Adelaide, SA, Australia
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3
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Narita T, Nakane S, Nagaishi A, Minami N, Niino M, Kawaguchi N, Murai H, Kira JI, Shimizu J, Iwasa K, Yoshikawa H, Hatanaka Y, Sonoo M, Shimizu Y, Matsuo H. Immunotherapy for ocular myasthenia gravis: an observational study in Japan. Ther Adv Neurol Disord 2023; 16:17562864231163819. [PMID: 37051222 PMCID: PMC10084546 DOI: 10.1177/17562864231163819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/27/2023] [Indexed: 04/14/2023] Open
Abstract
Background Treatment for ocular myasthenia gravis (OMG) has not yet been well established. Few reports have been published on the clinical practice and outcomes of OMG. Objectives We investigated treatment of OMG and its outcomes in Japan.We investigated treatment of OMG and its outcomes in Japan. Design We performed a retrospective cross-sectional survey of OMG patients from eight hospitals in Japan. Methods Clinical information, including sex, age at onset, initial symptoms, autoantibodies, clinical course, treatment history, complications, and outcomes, was obtained. In addition, we recorded the total number of patients with MG and OMG separately. Results In total, 135 patients with OMG (67 men, 68 women) were included. Treatment of OMG was not simple and involved various immunotherapeutic strategies. Eight patients went into remission spontaneously without immunotherapy. A total of 117 patients showed improvements after treatment, whereas 10 patients showed refractory responses to treatment. Overall outcomes were good; however, symptoms persisted in 60.7% of patients even after treatment. Among 90 patients who received immunotherapy, only two showed a refractory response. Meanwhile, for 45 patients who did not receive immunotherapy, 8 were refractory. Thus, the rate of refractory disease in the group with immunotherapy was significantly lower (p = 0.001, u-test) than in the group without immunotherapy. The proportion of generalized MG patients among all MG cases was low in medical centers where immunotherapy for OMG was frequently performed. Conclusion Although the overall prognosis for patients with OMG was good, symptoms remained in more than half of the patients. Immunotherapy, including corticosteroids, may be beneficial for patients with OMG. Plain language summary Is immunosuppressive therapy beneficial for myasthenia gravis patients with ocular symptoms only? Patients with ocular myasthenia gravis (OMG) have only eye symptoms for more than 2 years. Whether this condition is an initial stage of the disease before eventually progressing to generalized myasthenia gravis (gMG) is still uncertain. Different from gMG, OMG is not life-threatening. But eye symptoms often cause troublesome problems in life. Doctors have treated OMG patients similarly to patients with gMG. There is no standard clinical practice for OMG. In this study, we examined how patients with OMG were treated at eight different specialist centers in Japan. In 135 patients with OMG, 8 patients became symptom free without treatment, 117 patients showed improvements after treatment, whereas 10 patients did not get well. Overall outcomes were good, but symptoms remained in 60.7% of patients even after treatment. Among 90 patients who received one or more immunotherapies, only 2 did not get well. Meanwhile, for 45 patients who did not receive immunotherapy, 8 remained ill. We found that treatment of OMG was not simple and often needed multiple immunotherapies. Administering immunotherapy, including corticosteroids, may be beneficial for patients with OMG.
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Affiliation(s)
| | | | - Akiko Nagaishi
- Department of Neurology, National Hospital Organization, Nagasaki Kawatana Medical Center, Nagasaki, Japan
| | - Naoya Minami
- Department of Neurology, National Hospital Organization, Hokkaido Medical Center, Sapporo, Japan
| | - Masaaki Niino
- Department of Neurology, National Hospital Organization, Hokkaido Medical Center, Sapporo, Japan
| | | | - Hiroyuki Murai
- Department of Neurology, Neurological Institute, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
- Department of Neurology, International University of Health and Welfare, Tokyo, Japan
| | - Jun-ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Jun Shimizu
- Department of Neurology, Tokyo University, Tokyo, Japan
| | - Kazuo Iwasa
- Department of Neurology and Neurobiology of Aging, Kanazawa University, Kanazawa, Japan
| | - Hiroaki Yoshikawa
- Department of Neurology and Neurobiology of Aging, Kanazawa University, Kanazawa, Japan
- Health Service Center, Kanazawa University, Kanazawa, Japan
| | - Yuki Hatanaka
- Department of Neurology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Masahiro Sonoo
- Department of Neurology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Yuko Shimizu
- Department of Neurology, School of Medicine, Tokyo Women’s Medical University, Tokyo, Japan
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4
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Markow MB, Ren D, Andrews A, DiFazio M. Isolated Unilateral Ptosis in a 5-year-old Boy. Pediatr Rev 2022; 43:721-723. [PMID: 36450634 DOI: 10.1542/pir.2020-004176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
| | | | - Alex Andrews
- Division of Neurology, Children's National Hospital, Washington, DC
| | - Marc DiFazio
- Division of Neurology, Children's National Hospital, Washington, DC
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5
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Heckmann JM, Europa TA, Soni AJ, Nel M. The Epidemiology and Phenotypes of Ocular Manifestations in Childhood and Juvenile Myasthenia Gravis: A Review. Front Neurol 2022; 13:834212. [PMID: 35280301 PMCID: PMC8904732 DOI: 10.3389/fneur.2022.834212] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/24/2022] [Indexed: 11/28/2022] Open
Abstract
Myasthenia gravis (MG) appears to have a similar incidence among adult populations worldwide. However, epidemiological and phenotypic differences have been noted among children and juveniles with MG. We reviewed the literature on childhood- and juvenile-onset MG among different populations, with the focus on ocular involvement, antibody profiles, the genetic susceptibility to juvenile MG phenotypes, the use of immune treatments, and the reported responses of extraocular muscles to therapies. Although epidemiological studies used different methodologies, reports from Asia, compared to Europe, showed more than two-fold higher proportions of prepubertal onset (before 12 years) vs. postpubertal-onset juveniles with MG. Compared to European children, ocular MG was 4-fold more frequent among Asian children, and 2–3-fold more frequent among children with African ancestry both in prepubertal and postpubertal ages at onset. These results suggest genetic influences. In Asia, HLA-B*46 and DRB1*09 appeared overrepresented in children with ocular MG. In Europe, children with MG had a significantly higher rate of transforming from ocular to generalized disease and with an overrepresentation of HLADRB1*04. Although treatment regimens vary widely and the responses to immune therapies of the ocular muscles involved in MG were generally poorly described, there were indications that earlier use of steroid therapy may have better outcomes. Reports of treatment-resistant ophthalmoplegia may be more frequent in African and Asian juvenile MG cohorts compared to Europeans. Genetic and muscle gene expression studies point to dysregulated muscle atrophy signaling and mitochondrial metabolism pathways as pathogenetic mechanisms underpinning treatment-resistant ophthalmoplegia in susceptible individuals. In conclusion, phenotypic differences in juveniles with ocular manifestations of MG were evident in different populations suggesting pathogenetic influences. Treatment responses in MG-associated ocular disease should attract more careful descriptive reports. In MG, extraocular muscles may be vulnerable to critical periods of poor force generation and certain individuals may be particularly susceptible to developing treatment-resistant ophthalmoplegia. The development of prognostic biomarkers to identify these susceptible individuals is an unmet need.
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Affiliation(s)
- Jeannine M Heckmann
- Division of Neurology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Neurology Research Group, University of Cape Town (UCT) Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Tarin A Europa
- Division of Neurology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Neurology Research Group, University of Cape Town (UCT) Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Aayesha J Soni
- Division of Neurology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Melissa Nel
- Neurology Research Group, University of Cape Town (UCT) Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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6
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Myasthenia Gravis Masquerading as Status Asthmaticus. Case Rep Pediatr 2022; 2021:6959701. [PMID: 34992892 PMCID: PMC8727132 DOI: 10.1155/2021/6959701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/23/2021] [Accepted: 12/03/2021] [Indexed: 11/18/2022] Open
Abstract
Myasthenia gravis, an autoimmune disorder of neuromuscular transmission, can lead to varying degrees of weakness and fatigability of the skeletal musculature. Juvenile myasthenia gravis accounts for 10–15% of all cases of myasthenia gravis. The clinical presentation of juvenile myasthenia gravis varies tremendously, which presents itself as a diagnostic challenge for clinicians. We report a case of a 15-year-old female with mild intermittent asthma presenting with shortness of breath. Acute onset of dyspnea is a common chief complaint amongst the pediatric population with a broad differential diagnosis. Our patient was presumptively treated for status asthmaticus and required invasive mechanical ventilation. After extubating, the patient showed persistent ptosis, which led to the eventual work-up of myasthenia gravis. Upon further review, this patient had months of intermittent symptoms including ptosis and fatigue which went previously undiagnosed. This case demonstrates that dyspnea in an asthmatic can occur from nonairway processes and, if missed, may result in overtreatment of asthma or delayed diagnosis of an important neuromuscular process.
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Barsoum Z. Pediatric Miller Fisher Syndrome and Ocular Myasthenia Gravis (A Reminder of Clinical Mimicry): A Case Report. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1732484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractMiller Fisher syndrome (MFS) is a rare immune-mediated neuropathy that often presents with diplopia and bilateral external ophthalmoplegia. Other neurological deficits may occur such as ataxia and areflexia but not in all cases. Although MFS is a clinical diagnosis, serological confirmation is possible by identifying the anti-GQ1b antibody found in the majority of patients. Myasthenia gravis is an autoimmune disorder of the availability of acetylcholine receptors in the neuromuscular junction. Ocular myasthenia gravis is a disease subtype characterized by variable patterns of weakness of extraocular muscles, eyelid elevator, and orbicular muscle in which the initial sign in most adults and children is ptosis. We report a child with MFS who presented with clinical signs suggestive of ocular myasthenia gravis, but in whom the correct diagnosis was made on the basis of serological testing for the anti-GQ1b antibody. We aim to highlight the similarity between the two rare conditions and address the importance of early liaison with neurologists and ophthalmologists in reaching to the proper diagnosis.
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Affiliation(s)
- Zakaria Barsoum
- Department of Paediatric, South West Acute Hospital, Enniskillen, Northern Ireland, United Kingdom
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8
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Jain R, Aulakh R. Pediatric Ocular Myasthenia Gravis: A Review. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1721401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractPediatric ocular myasthenia gravis (OMG) is difficult to diagnose and manage, owing to its rarity and low index of suspicion in the early stage of the disease. Also, many other conditions having similar presentation cause a further delay in diagnosis. In this review, we highlighted various pointers in history and described bedside clinical tests that can aid in its timely diagnosis. The antibody spectrum in myasthenia is ever increasing and includes anti-muscle specific kinase and low-density lipoprotein-receptor related protein 4 antibodies in addition to acetylcholine receptor antibodies besides many others. However, pediatric OMG patients often test negative for all three antibodies, making the diagnosis even more difficult in triple seronegative patients. Edrophonium and electrophysiological tests, which help in confirming myasthenia in adults, have a limited utility in diagnosing pediatric ocular myasthenia cases. Various practical difficulties are encountered like nonavailability of edrophonium, risk of bradycardia associated with neostigmine use and its lower sensitivity, noncooperative children, and limited technical expertise in performing electrophysiological tests in children. In this article, we described a pragmatic approach to diagnose pediatric OMG along with the important aspects of its management.
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Affiliation(s)
- Reena Jain
- Department of Pediatrics, Government Medical College & Hospital, Chandigarh, India
| | - Roosy Aulakh
- Department of Pediatrics, Government Medical College & Hospital, Chandigarh, India
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9
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Fisher KS, Gill J, Todd HF, Yang MB, Lopez MA, Abid F, Lotze T, Shah VS. Pediatric Autoimmune Ocular Myasthenia Gravis: Evaluation of Presentation and Treatment Outcomes in a Large Cohort. Pediatr Neurol 2021; 118:12-19. [PMID: 33684630 DOI: 10.1016/j.pediatrneurol.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND In autoimmune myasthenia gravis (MG), autoantibodies target the neuromuscular junction. Ocular myasthenia gravis (OMG) is localized, affecting only extraocular and/or levator palpebrae muscles. OMG presents across all ages, varying in presentation, treatment modalities, and outcomes. Recently, there have been advances in MG/OMG treatment; their utilization and effectiveness are an important part of optimal disease management. METHODS We completed a retrospective chart review of children aged 18 years or younger with a confirmed diagnosis of OMG presenting from 2002 to 2019. RESULTS Forty-two patients were included with mean age at presentation of 8.5 years (2 to 18 years). Twenty-one patients (50%) had positive antibodies; 90% had acetylcholine receptor antibodies. Ten patients developed generalized symptoms with mean time to generalization of 13.6 months. Multiple logistic regression showed that older age of onset was a trend predictive factor (P = 0.054; odds ratio 1.17) for generalized disease. All patients were treated with pyridostigmine. Immunomodulating agents included steroids (15), mycophenolate mofetil (four), and intravenous immunoglobulin (one). Three patients underwent thymectomy. Twenty patients reached minimal manifestation status, and 12 achieved remission. Gender, race, and positive antibody status were not statistically significant predictors for advanced immunosuppressive therapy. CONCLUSIONS We summarize one of the largest cohorts of pediatric patients with OMG who have undergone up-to-date diagnostic and therapeutic regimens. The predictors of outcome and treatment pathway for OMG patients suggested by this report may be further elucidated by future prospective studies.
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Affiliation(s)
- Kristen S Fisher
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jason Gill
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | - Michael B Yang
- Division of Pediatric Ophthalmology, Abrahamson Pediatric Eye Institute, Cincinnati, Ohio; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael A Lopez
- Hess Pediatric Ophthalmology Specialist, St. Petersburg, Florida
| | - Farida Abid
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Timothy Lotze
- Department of Pediatric Neurology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Veeral S Shah
- Division of Pediatric Ophthalmology, Abrahamson Pediatric Eye Institute, Cincinnati, Ohio; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati College of Medicine, Cincinnati, Ohio.
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10
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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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11
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Xu L, Castro D, Reisch JS, Iannaccone ST. Response to treatment in pediatric ocular myasthenia gravis. Muscle Nerve 2019; 61:226-230. [PMID: 31650555 DOI: 10.1002/mus.26745] [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] [Received: 02/15/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Juvenile myasthenia gravis (JMG), a pediatric autoimmune neuromuscular junction disorder, includes generalized (GMG), and ocular (OMG) variants. We sought to determine whether differences existed between OMG and GMG children regarding demographics or treatment response. METHODS We performed retrospective analysis of 60 children with JMG seen between 1990 and 2018. Osserman scores were used to define OMG and GMG. The myasthenia scale of Millichap and Dodge was used to assess treatment responses. RESULTS There were no differences between GMG and OMG regarding time interval from disease onset to prednisone initiation (P = .42), or treatment response according to Millichap and Dodge (P = .12). Compared with GMG, OMG children showed younger age of disease onset and better outcomes after treatment. No OMG patients progressed to generalized disease during the follow-up period. DISCUSSION Compared with GMG, OMG patients had earlier disease onset and improved outcomes after treatment.
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Affiliation(s)
| | - Diana Castro
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joan S Reisch
- Division of Biostatistics, Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Susan T Iannaccone
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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13
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Repka MX. Don't Miss This! Red Flags in the Pediatric Eye Examination: Ophthalmoplegia in Childhood. J Binocul Vis Ocul Motil 2019; 69:93-97. [PMID: 31329057 DOI: 10.1080/2576117x.2019.1590141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/16/2019] [Accepted: 02/22/2019] [Indexed: 06/10/2023]
Abstract
Paralytic strabismus in children is rare, occurring in about 0.1% of children. This rate is far less common than the 3% rate usually noted for comitant strabismus. The relative rates of ocular motor pareses were fourth nerve palsies in 36%, sixth in 33%, third in 22%, with multiple ocular motor nerve palsies in 9%. In a single population series from Minnesota, few cases were associated with neoplasm. However, institutional case series reports a high rate of neoplasm for acquired third nerve and sixth nerve palsies after excluding trauma and congenital causes. Tumor is rare in children with fourth cranial nerve palsies, usually associated with other neurologic disease. Rare causes of external ophthalmoplegia, to be considered when the motility pattern is variable or not fitting an ocular motor nerve pattern, include myasthenia gravis and congenital fibrosis of the extraocular muscles. Myasthenia most often presents as ptosis with exotropia. Rarer still is involvement of the extraocular muscles in childhood thyroid disease.
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Affiliation(s)
- Michael X Repka
- a Ophthalmology, Johns Hopkins University School of Medicine , Baltimore , Maryland , USA
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14
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Abstract
PURPOSE A randomized controlled trial of thymectomy in myasthenia gravis demonstrated improved clinical outcomes in adults, but data surrounding juvenile cases, especially those treated with minimally invasive approaches, are limited. Here, we review our experience with thoracoscopic thymectomy for juvenile myasthenia gravis (JMG) in the largest cohort to date. METHODS All cases of thymectomy for JMG in a single tertiary referral center between 2007 and 2018 were reviewed (N = 50). Patients underwent left thoracoscopic approach with extended dissection and without use of monopolar energy. Demographics, diagnostic criteria, and clinical classification, as well as surgical data were collected. Clinical status and medications were reviewed in follow-up. RESULTS The mean age at surgery was 10.5 ± 0.8 years. Ocular disease and generalized disease each comprised half of the cohort. No patients suffered complications or increased risk of morbidity or mortality with thymectomy. At any interval of follow-up through 3.5 years, 49.8% of patients were improved compared to their pre-operative presentation, and there was a significant trend towards decreased steroid use. CONCLUSION Thoracoscopic thymectomy is a safe treatment for juvenile myasthenia gravis in pediatric patients over a wide range of ages, body masses, and symptoms. Our experience adds evidence that pediatric patients likely benefit from thymectomy with improved clinical status and reduced medications.
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Affiliation(s)
- Aimee G. Kim
- Division of Pediatric General, Thoracic and Fetal Surgery, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Sydney A. Upah
- Division of Pediatric General, Thoracic and Fetal Surgery, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - John F. Brandsema
- Division of Neurology, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Sabrina W. Yum
- Division of Neurology, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Thane A. Blinman
- Division of Pediatric General, Thoracic and Fetal Surgery, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
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Juvenile Ocular Myasthenia Gravis: Presentation and Outcome of a Large Cohort. Pediatr Neurol 2018; 87:36-41. [PMID: 30197221 DOI: 10.1016/j.pediatrneurol.2018.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 06/19/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Isolated ocular myasthenia gravis (MG) is sparingly common in children relative to adults, ranging from 71% to 93% of all children with MG. PURPOSE We aimed to characterize the ocular manifestations and outcomes in children with isolated ocular MG. METHODS Medical records of consecutive 62 subjects less than 15 years of age with ocular MG, were retrospectively reviewed. Demographic data, presenting ocular features, types and variabilities of duction limitation, MG confirmatory tests, types of and responses to treatment, and generalized MG conversion were reviewed. RESULTS Mean age at onset and follow-up time were 49 months (range, one to 173 months) and 95 months (range, six to 226 months), respectively. Female-to-male ratio was 1.5:1. Initially, ptosis was found in 60 subjects (96.8%), while duction limitation was observed in 28 subjects (45.2%). Total ophthalmoparesis was the most common type of duction limitation. Variability of duction limitation was found in 68% of subjects during the follow-up. Pyridostigmine alone was the most common medication used (48.4%); ptosis was more responsive to therapy than duction limitation. Conversion to generalized MG occurred in 19.4% of subjects, with a mean interval to conversion of nine months after symptom onset. Most conversions (91.7%) occurred in the first two years. CONCLUSIONS Ptosis was more responsive to treatment than duction limitation. Thus other treatment modalities, as well as strabismic amblyopia screening, should be considered in children with prolonged duction limitation that is refractory to medication. In contrast with adults, a much lower proportion of children converted to generalized MG. This may explain the higher prevalence of isolated ocular MG among the juvenile population.
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Abstract
Objectives To describe the clinical profile, clinical outcomes and factors that may affect the outcome of juvenile myasthenia gravis (JMG) patients in southern China. Methods We reviewed information relating to JMG patients treated and evaluated at the First Affiliated Hospital, Sun Yat-sen University, between 1998 and 2015. The study involved 327 JMG patients who had been followed up for ≥1 year. Results Overall, 77.4% patients showed initial symptoms in the prepubertal period (<12 years). 306 patients showed only ocular symptoms at onset. By the final follow-up, 61 ocular myasthenia gravis (OMG) patients (61/306, 19.9%) had developed generalized myasthenia gravis (GMG). Anti-acetylcholine receptor antibodies (AChR-Ab) titer was an independent risk factor for generalization. Eleven patients (3.4%) experienced spontaneous remission, but four relapsed. Low-dose oral prednisone (0.25 mg/kg) was administered when symptoms did not significantly improve after pyridostigmine treatment. Immunosuppressants were administered when prednisone was unsatisfactory. Optimal outcome was achieved in 59.6% of patients. Specifically, 60 patients (18.3%) attained complete stable remission (CSR), 12 (3.7%) attained pharmaceutical remission (PR), and 123 (37.6%) attained minimal manifestation (MM). In total, 53 OMG patients (21.5%) attained CSR, a significantly higher proportion than among the GMG patients (8.6%, P = 0.009). Moreover, 67.2% of patients with duration <2 years showed significant clinical improvement compared with 46.3% of those with duration >2 years (P < 0.001). Thymectomy did not exhibit definite efficacy for JMG patients. Conclusion There was a low frequency of cases positive for AChR-Ab in the Chinese population. AChR-Ab titer was revealed as an independent risk factor for generalization. Low doses of prednisone could treat JMG effectively with few side effects.
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Affiliation(s)
- Xin Huang
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
| | - Yingkai Li
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huiyu Feng
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pei Chen
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weibin Liu
- Department of Neurology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Diseases, Guangzhou, China
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Barraud C, Desguerre I, Barnerias C, Gitiaux C, Boulay C, Chabrol B. Clinical features and evolution of juvenile myasthenia gravis in a French cohort. Muscle Nerve 2017; 57:603-609. [PMID: 28877546 DOI: 10.1002/mus.25965] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2017] [Indexed: 01/17/2023]
Abstract
INTRODUCTION In this study we determined the clinical, paraclinical, and treatment-related features of juvenile myasthenia gravis (JMG) as well as the clinical course in a cohort of French children. METHODS We conducted a retrospective study of 40 patients with JMG at 2 French pediatric neurology departments from April 2004 to April 2014. RESULTS Among the patients, 70% had generalized JMG, 52% had positive acetylcholine receptor antibodies, 8% had muscle-specific kinase antibodies, and 40% were seronegative. Treatment with acetylcholinesterase inhibitors was effective and sufficient in 47% of patients. The 6 patients with generalized JMG treated with rituximab and/or immunoadsorption showed improvement. Thirty percent of the patients required hospitalization in an intensive care unit during follow-up (mean 4.7 years). Remission without treatment occurred in 18% of patients. DISCUSSION As with adults, JMG has high morbidity, particularly among children with generalized symptoms, and rituximab should be considered early in the course of the disease as a second-line treatment. Muscle Nerve 57: 603-609, 2018.
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Affiliation(s)
- Coline Barraud
- APHM Service de Neuropédiatrie, Hôpital La Timone-Enfants, 264, Rue St Pierre Marseille, 13385, cedex 5, France
- Aix-Marseille Université, Marseille, France
| | - Isabelle Desguerre
- APHP Service de Neuropédiatrie, Hôpital Necker-Enfants Malades, Paris, France
- Université René Descartes, Paris, France
| | - Christine Barnerias
- APHP Service de Neuropédiatrie, Hôpital Necker-Enfants Malades, Paris, France
| | - Cyril Gitiaux
- Aix-Marseille Université, Marseille, France
- APHP Service de Neuropédiatrie, Hôpital Necker-Enfants Malades, Paris, France
| | - Christophe Boulay
- APHM Service de Neuropédiatrie, Hôpital La Timone-Enfants, 264, Rue St Pierre Marseille, 13385, cedex 5, France
- Aix-Marseille Université, Marseille, France
| | - Brigitte Chabrol
- APHM Service de Neuropédiatrie, Hôpital La Timone-Enfants, 264, Rue St Pierre Marseille, 13385, cedex 5, France
- Aix-Marseille Université, Marseille, France
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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.
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Vázquez-Roque F, Hernández-Oliver M, Medrano Plana Y, Castillo Vitlloch A, Fuentes Herrera L, Rivero-Valerón D. Resultados del tratamiento quirúrgico en la miastenia gravis juvenil. Neurologia 2017; 32:137-142. [DOI: 10.1016/j.nrl.2015.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 08/15/2015] [Accepted: 09/02/2015] [Indexed: 10/22/2022] Open
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Vázquez-Roque F, Hernández-Oliver M, Medrano Plana Y, Castillo Vitlloch A, Fuentes Herrera L, Rivero-Valerón D. Results of surgical treatment for juvenile myasthenia gravis. NEUROLOGÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.nrleng.2015.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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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.
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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
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Nair AG, Patil-Chhablani P, Venkatramani DV, Gandhi RA. Ocular myasthenia gravis: a review. Indian J Ophthalmol 2016; 62:985-91. [PMID: 25449931 PMCID: PMC4278125 DOI: 10.4103/0301-4738.145987] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Myasthenia gravis (MG) is a disease that affects the neuro-muscular junction resulting in classical symptoms of variable muscle weakness and fatigability. It is called the great masquerader owing to its varied clinical presentations. Very often, a patient of MG may present to the ophthalmologist given that a large proportion of patients with systemic myasthenia have ocular involvement either at presentation or during the later course of the disease. The treatment of ocular MG involves both the neurologist and ophthalmologist. Thus, the aim of this review was to highlight the current diagnosis, investigations, and treatment of ocular MG.
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Affiliation(s)
| | - Preeti Patil-Chhablani
- Department of Strabismus and Neuro-Ophthalmology, Jasti V Ramanamma Children's Eye Care Centre, Hyderabad, Telangana, India
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Jovandaric MZ, Despotovic DJ, Jesic MM, Jesic MD. Neonatal Outcome in Pregnancies with Autoimmune Myasthenia Gravis. Fetal Pediatr Pathol 2016; 35:167-72. [PMID: 27100475 DOI: 10.3109/15513815.2016.1164773] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Acquired autoimmune myasthenia gravis (MG) is an autoimmune process in which antibodies (AB) directed against the acetylcholine nicotinic receptor (AChR) cause weakness and fatigue of striated muscles. OBJECTIVES The objective of this study was to determine the range of clinical manifestations in newborns with transient neonatal myasthenia (TNM). METHODS 62 newborns with mothers who had autoimmune MG were followed by: anthropometric parameters, gestational age, gender, type of delivery completion, Apgar score (AS) in the first and fifth minute, and the emergence of TNM symptoms. RESULTS For fourteen consecutive years, from a total of 98,000 infants, 62 (0.06%) were born to mothers with autoimmune MG. Four of them (6.4%) had symptoms of TNM. CONCLUSION Newborns of mothers with MG manifest clinical features of TNM relative to stage of mother's illness. These newborns need monitoring until the seventh day of life.
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Affiliation(s)
- Miljana Z Jovandaric
- a Department of Neonatology , Clinic for Gynecology and Obstetrics, Clinical Center of Serbia , Belgrade , Serbia
| | - Dina J Despotovic
- a Department of Neonatology , Clinic for Gynecology and Obstetrics, Clinical Center of Serbia , Belgrade , Serbia
| | - Milos M Jesic
- b Department of Neonatology , School of Medicine, University of Belgrade, University Children's Hospital , Belgrade , Serbia
| | - Maja D Jesic
- c Department of Endocrinology , School of Medicine, University of Belgrade, University Children's Hospital , Belgrade , Serbia
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Chappaz A, Knirsch U, Gerth-Kahlert C. Alternating IV nerve palsy and ptosis as a first sign of childhood ocular myasthenia gravis. Pediatr Neurol 2015; 52:460-1. [PMID: 25661284 DOI: 10.1016/j.pediatrneurol.2014.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 11/18/2014] [Accepted: 12/23/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Ariane Chappaz
- Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland
| | - Ursula Knirsch
- Department of Pediatric Neurology, University Children's Hospital, Zurich, Switzerland
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Litwin AS, Patel B, McNab AA, McCann JD, Leatherbarrow B, Malhotra R. Blepharoptosis surgery in patients with myasthenia gravis. Br J Ophthalmol 2015; 99:899-902. [DOI: 10.1136/bjophthalmol-2014-306335] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/26/2014] [Indexed: 11/03/2022]
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Strabismus surgery and long-term visual outcomes in patients with preadolescent onset ocular myasthenia gravis. Graefes Arch Clin Exp Ophthalmol 2014; 253:157-63. [DOI: 10.1007/s00417-014-2847-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 09/23/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022] Open
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An adult patient with ocular myasthenia and unusually long spontaneous remission. Case Rep Neurol Med 2014; 2014:372769. [PMID: 24822137 PMCID: PMC4005048 DOI: 10.1155/2014/372769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 03/31/2014] [Indexed: 11/17/2022] Open
Abstract
A male patient developed ocular myasthenia gravis (MG) at the age of 33. He was anti-acetylcholine receptor antibody (anti-AChR Ab) negative. He received cholinesterase blocker for 5 months and went into a complete clinical remission that lasted untreated for 17 years. He relapsed recently with ocular symptoms only. He is now anti-AChR Ab positive and SFEMG is abnormal in a facial muscle. The patient is controlled with steroids. He had one of the longest spontaneous remissions reported in the natural history of MG, particularly unusual for an adult with the disease.
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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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Kerty E, Elsais A, Argov Z, Evoli A, Gilhus NE. EFNS/ENS Guidelines for the treatment of ocular myasthenia. Eur J Neurol 2014; 21:687-93. [PMID: 24471489 DOI: 10.1111/ene.12359] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 12/17/2013] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE The symptoms of acquired autoimmune ocular myasthenia are restricted to the extrinsic eye muscles, causing double vision and drooping eyelids. These guidelines are designed to provide advice about best clinical practice based on the current state of clinical and scientific knowledge and the consensus of an expert panel. SEARCH STRATEGY Evidence for these guidelines was collected by searches in the MEDLINE and Cochrane databases. The task force working group reviewed evidence from original articles and systematic reviews. The evidence was classified (I, II, III, IV) and consensus recommendation graded (A, B or C) according to the EFNS guidance. Where there was a lack of evidence but clear consensus, good practice points are provided. CONCLUSIONS The treatment of ocular myasthenia should initially be started with pyridostigmine (good practice point). If this is not successful in relieving symptoms, oral corticosteroids should be used on an alternate-day regimen (recommendation level C). If steroid treatment does not result in good control of the symptoms or if it is necessary to use high steroid doses, steroid-sparing treatment with azathioprine should be started (recommendation level C). If ocular myasthenia gravis is associated with thymoma, thymectomy is indicated. Otherwise, the role of thymectomy in ocular myasthenia is controversial. Steroids and thymectomy may modify the course of ocular myasthenia and prevent myasthenia gravis generalization (good practice point).
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Affiliation(s)
- E Kerty
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
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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.
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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.
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Abstract
BACKGROUND Approximately 50% of people with myasthenia gravis present with purely ocular symptoms, so called ocular myasthenia. Of these between 50% to 60% develop generalized disease, most within two years. Their management is controversial. This is an update of a review first published in 2006 and previously updated in 2008 and 2010. OBJECTIVES To assess the effects of treatments for ocular myasthenia and to answer three specific questions. Are there any treatments that impact the progression from ocular to generalized disease? Are there any treatments that improve symptoms of diplopia or ptosis? What is the frequency of adverse effects associated with treatments used? SEARCH METHODS In this updated review, we searched the Cochrane Neuromuscular Disease Group Specialized Register (3 August 2012), CENTRAL (2012, Issue 7), MEDLINE (January 1996 to July 2012) and EMBASE (January 1974 to July 2012) for randomized controlled trials (RCTs) as well as case-control and cohort studies. The titles and abstracts of all articles were read by both authors and the full texts of possibly relevant articles were reviewed. The references of all manuscripts included in the review were scanned to identify additional articles of relevance and experts in the field were contacted to identify additional published and unpublished data. Where necessary, we contacted authors for further information. SELECTION CRITERIA Inclusion required meeting three criteria: (a) randomized (or quasi-randomized) controlled study design; (b) active treatment compared to placebo, no treatment or some other treatment; and (c) results reported separately for patients with ocular myasthenia (grade 1) as defined by the Myasthenia Gravis Foundation of America. DATA COLLECTION AND ANALYSIS We collected data regarding the risk of progression to generalized myasthenia gravis, improvement in ocular symptoms, and the frequency of treatment-related side effects. MAIN RESULTS In the original review, we identified two RCTs relevant to the treatment of ocular myasthenia, only one of which reported results in terms of the pre-specified outcome measures used in this review. This study included only three participants and was of limited methodological quality. There were no new RCTs in searches conducted for this or previous updates. In the absence of data from RCTs, we present a review of the available observational data. AUTHORS' CONCLUSIONS The available randomized controlled literature does not permit any meaningful conclusions about the efficacy of any form of treatment for ocular myasthenia. Data from several reasonably good quality observational studies suggest that corticosteroids and azathioprine may be beneficial in reducing the risk of progression to generalized myasthenia gravis.
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Affiliation(s)
- Michael Benatar
- Department of Neurology, University of Miami, Miami, Florida, USA.
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Finnis MF, Jayawant S. Juvenile myasthenia gravis: a paediatric perspective. Autoimmune Dis 2011; 2011:404101. [PMID: 22110902 PMCID: PMC3206364 DOI: 10.4061/2011/404101] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 08/10/2011] [Indexed: 11/25/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease in which antibodies are directed against the postsynaptic membrane of the neuromuscular junction, resulting in muscle weakness and fatigability. Juvenile myasthenia gravis (JMG) is a rare condition of childhood and has many clinical features that are distinct from adult MG. Prepubertal children in particular have a higher prevalence of isolated ocular symptoms, lower frequency of acetylcholine receptor antibodies, and a higher probability of achieving remission. Diagnosis in young children can be complicated by the need to differentiate from congenital myasthenic syndromes, which do not have an autoimmune basis. Treatment commonly includes anticholinesterases, corticosteroids with or without steroid-sparing agents, and newer immune modulating agents. Plasma exchange and intravenous immunoglobulin (IVIG) are effective in preparation for surgery and in treatment of myasthenic crisis. Thymectomy increases remission rates. Diagnosis and management of children with JMG should take account of their developmental needs, natural history of the condition, and side-effect profiles of treatment options.
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Affiliation(s)
- Maria F Finnis
- Department of Paediatric Neurology, Children's Hospital, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Pineles SL, Avery RA, Moss HE, Finkel R, Blinman T, Kaiser L, Liu GT. Visual and systemic outcomes in pediatric ocular myasthenia gravis. Am J Ophthalmol 2010; 150:453-459.e3. [PMID: 20678749 DOI: 10.1016/j.ajo.2010.05.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Revised: 05/04/2010] [Accepted: 05/05/2010] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate visual and systemic outcomes in pediatric patients with purely ocular myasthenia gravis (OMG) treated at the Children's Hospital of Philadelphia. DESIGN Retrospective chart review. METHODS Pediatric patients with OMG seen at a single institution over a 16-year period with a minimum follow-up of 1 year were reviewed. Associations of demographic and clinical characteristics with disease resolution, amblyopia, and development of generalized symptoms of myasthenia gravis were analyzed. RESULTS Thirty-nine patients were identified, with a mean age of 5.4 ± 4.8 years and mean follow-up of 4.8 ± 4.3 years. Fifteen patients were treated with pyridostigmine only, 19 (49%) also received steroids, and 15 (38%) underwent thymectomy. Four patients (10%) received steroid-sparing immunosuppressive therapy. Resolution occurred in 10 patients, and generalized symptoms eventually occurred in 9 patients. Although 10 patients were treated for amblyopia, only 1 had amblyopia at the final visit. There was no correlation between sex or age with amblyopia or development of generalized symptoms. Thymectomy, when performed before the onset of generalized symptoms, showed a trend toward protection from the development of generalized symptoms (P = .07). CONCLUSIONS In our series, 24% of patients had disease resolution and 23% had generalized symptoms. Our larger cohort confirms previous findings that treated and untreated pediatric patients with OMG have a relatively low risk of developing generalized symptoms and that related amblyopia is readily reversible. Although our treatments were more aggressive than those previously reported, our rates of amblyopia and development of generalized symptoms are comparable.
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Affiliation(s)
- Stacy L Pineles
- Neuro-ophthalmology Service, Children's Hospital of Philadelphia, USA
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Liu GT, Volpe NJ, Galetta SL. Eyelid and facial nerve disorders. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00014-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
BACKGROUND Approximately 50% of people with myasthenia gravis present initially with purely ocular symptoms, so called ocular myasthenia and between 50 to 60% of these people will progress to develop generalized disease. The vast majority will do so within the first one to two years. There is controversy surrounding the appropriate management of patients with ocular myasthenia. OBJECTIVES To perform a systematic review of the literature relevant to the treatment of ocular myasthenia and to answer three specific questions. Are there any medical or surgical treatments that have an impact on the risk of progression from ocular to generalized myasthenia gravis? Are there any medical or surgical treatments that improve symptoms of diplopia or ptosis in ocular myasthenia? What is the frequency of side effects associated with treatments used in people with ocular myasthenia? SEARCH STRATEGY We searched the Cochrane Neuromuscular Disease Group Trials Register (searched December 2004), MEDLINE (1996 to 2004) and EMBASE (1980 to 2004) for randomized controlled trials as well as case-control and cohort studies. The titles and abstracts of all articles were read by both authors and the full text of all articles that were of possible relevance was reviewed in full. The references of all manuscripts included in the review were scanned to identify additional articles of relevance and experts in the field were contacted to identify additional published and unpublished data. Where necessary and possible, we contacted authors for further information. SELECTION CRITERIA To be included in the review, studies had to meet three criteria: (a) randomized (or quasi-randomized) controlled study design; (b) active treatment compared to placebo, no treatment or some other treatment; and (c) results reported separately for patients with ocular myasthenia (grade 1) as defined by the Myasthenia Gravis Foundation of America. DATA COLLECTION AND ANALYSIS We collected data regarding the risk of progression to generalized myasthenia gravis, improvement in ocular symptoms, and the frequency of treatment-related side effects. MAIN RESULTS We identified two randomized controlled trials relevant to the treatment of ocular myasthenia, only one of which reported results in terms of the pre-specified outcome measures used in this review. This study included only three participants and was of limited methodological quality. In the absence of data from randomized controlled trials, we present a review of the available observational data. AUTHORS' CONCLUSIONS There are no data from randomized controlled trials on the impact of any form of treatment on the risk of progression from ocular to generalized myasthenia gravis. The available randomized controlled literature does not permit any meaningful conclusions about the efficacy of any form of treatment for ocular myasthenia. Data from several reasonably good quality observational studies suggest that corticosteroids and azathioprine may be beneficial in reducing the risk of progression to generalized myasthenia gravis.
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Affiliation(s)
- M Benatar
- Emory University, Neurology Department, 1365A Clifton Road NE, Atlanta, GA 30322, USA.
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