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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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Cao Y, Gui M, Ji S, Bu B. Guillain-Barré syndrome associated with myasthenia gravis: Three cases report and a literature review. Medicine (Baltimore) 2019; 98:e18104. [PMID: 31764848 PMCID: PMC6882608 DOI: 10.1097/md.0000000000018104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Myasthenia gravis (MG) and Guillain-Barré syndrome (GBS) are 2 common neurologic autoimmune diseases. Although both the diseases can present with acute or subacute onset of muscular weakness involving the limbs and bulb, the coexistence in the same patient is unusual and rarely described in the literature. PATIENT CONCERNS Three cases of combined MG and GBS at the department of Neurology were described. All the 3 patients developed GBS, who had had MG for 30 years, 6 years, and 6 months, respectively. DIAGNOSES The newly developed GBS was clinically confirmed by the clinical features, electromyographic (EMG) studies, typical albumino-cytologic dissociation in cerebrospinal fluid (CSF), and positive anti-ganglioside antibodies in serum. INTERVENTIONS The 3 patients had been treated with intravenous immunoglobulin (IVIG), or plasma-exchange (PE), or IVIG combined with PE in the acute stage of severe muscle weakness. In light of the MG symptoms, they have received glucocorticoids, oral pyridostigmine, and immunosuppressive agents. OUTCOMES The patient 1 was able to walk longer than 5 m with assistance (Hughes 3). The patient 2 had significantly improved, and completely recovered at the 1-year follow-up (Hughes 0). But unfortunately, the patient 3 was severely disabled and chair-bound at the last interview (Hughes 4). LESSONS The combination of MG and GBS is quite rare. Limbs and oculo-bulbar weakness are the cardinal manifestations of both the diseases. Although their characteristics are quite different, there are still some difficulties in diagnosing them when they occur in the same patient. Early diagnosis and proper treatment will yield satisfactory prognosis. Further researches are needed to elucidate the pathogenesis of the coexistence.
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Rodríguez Y, Vatti N, Ramírez-Santana C, Chang C, Mancera-Páez O, Gershwin ME, Anaya JM. Chronic inflammatory demyelinating polyneuropathy as an autoimmune disease. J Autoimmun 2019; 102:8-37. [DOI: 10.1016/j.jaut.2019.04.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/13/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022]
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Yuan J, Zhang J, Zhang B, Hu W. The clinical features of patients concurrent with Guillain-Barre syndrome and myasthenia gravis. ACTA ACUST UNITED AC 2018; 23:66-70. [PMID: 29455227 PMCID: PMC6751915 DOI: 10.17712/nsj.2018.1.20170209] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate all the coincidence cases of Guillain-Barre syndrome (GBS) and myasthenia gravis (MG). METHODS We performed web-based research of the overlapping incidence of GBS and MG in studies occurring from 1982 to 2016 and restricted to the English language. RESULTS Among 15 cases, an elevated CSF protein level without pleocytosis was found in 10 cases (66.7%); reduced nerve conduction was found in 13 cases (86.6%); a positive repetitive nerve stimulation test occurred in 11 cases (73.3%); anti-AChR antibodies were found in 13 cases (86.6%); anti-GQ1b antibodies were found in 6 cases (40%); a positive edrophonium chloride test was present in 10 cases (66.7%); and a co-occurring thymoma or thymectomy occurred in 4 cases (26.6%). The MG co-occurred with acute inflammatory demyelinating polyneuropathy (AIDP) in 8 cases and with Miller Fisher Syndrome in 5 cases. Treatment in the assessed cases included pyridostigmine (10 cases), prednisolone (7 cases), intravenous immunoglobulin (9 cases), plasmapheresis (3 cases), combined intravenous immunoglobulin and plasmapheresis in one case, and immunosuppressive drugs in 2 cases (azathioprine). Functional outcome was mentioned in 13 patients. The prognosis was favorable in 8 of the 15 recorded patients (Hughes 0-1), and 2 cases resulted in death. CONCLUSION Although comorbidity of GBS and MG is extremely rare, early recognition of this combination of inflammation of peripheral nerves and the neuromuscular junction is of great importance for both initial treatment and a better prognosis.
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Affiliation(s)
- Junliang Yuan
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University,Beijing,China
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Quan W, Xia J, Tong Q, Lin J, Zheng X, Yang X, Xie D, Weng Y, Zhang X. Myasthenia gravis and chronic inflammatory demyelinating polyneuropathy in the same patient – a case report. Int J Neurosci 2017; 128:570-572. [PMID: 29073825 DOI: 10.1080/00207454.2017.1398160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Weiwei Quan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Junhui Xia
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qiuling Tong
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jie Lin
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaolu Zheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xuezhi Yang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Dewei Xie
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yiyun Weng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xu Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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VanderPluym J, Vajsar J, Jacob FD, Mah JK, Grenier D, Kolski H. Clinical characteristics of pediatric myasthenia: a surveillance study. Pediatrics 2013; 132:e939-44. [PMID: 24019417 DOI: 10.1542/peds.2013-0814] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate the incidence, clinical features, diagnostic, and treatment trends of pediatric myasthenia in Canada. METHODS Through established Canadian Pediatric Surveillance Program methodology, physicians were anonymously surveyed for cases of pediatric myasthenia using a standardized clinical questionnaire containing deidentified data. Inclusion criteria were any child <18 years old with ≥1 of the following: (1) fluctuating ptosis or extraocular weakness, (2) skeletal muscle weakness or fatigue, and (3) any of the following supportive tests: clinical response to acetylcholinesterase inhibitor, positive antibodies, abnormal slow repetitive nerve stimulation, or single-fiber electromyography. RESULTS In 2 years of surveillance, 57 confirmed cases were reported. There were 34 generalized and 18 ocular reports of juvenile myasthenia gravis plus 5 congenital myasthenic syndrome cases. There were 14 incident cases in 2010 and 6 in 2011. Age of onset ranged from "birth" to 17 years for the generalized form compared with 18 months to 11 years for the ocular subtype. Positive acetylcholine receptor titers were found in 22 (67%) of 33 generalized cases and 8 (44%) of 18 ocular patients. Of patients started on pyridostigmine, improvement was noted in 33 (100%) of 33 generalized cases and 15 (88%) of 17 ocular cases. CONCLUSIONS This study represents the largest descriptive series of pediatric myasthenia in North America and provides valuable information about clinical characteristics. A high index of suspicion is important for this treatable disease. Children generally respond promptly to readily available therapies.
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Affiliation(s)
- Juliana VanderPluym
- Department of Pediatric Neurology, University of Alberta, 3-574A ECHA 11405-87 Ave, Edmonton, AB T6G 1C9, Canada.
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Riekhoff AGM, Jadoul C, Mercelis R, Cras P, Ceulemans BPGM. Childhood chronic inflammatory demyelinating polyneuroradiculopathy--three cases and a review of the literature. Eur J Paediatr Neurol 2012; 16:315-31. [PMID: 22225859 DOI: 10.1016/j.ejpn.2011.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 11/30/2011] [Accepted: 12/03/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic inflammatory demyelinating polyneuroradiculopathy (CIDP) is an autoimmune disease of the peripheral nervous system, causing demyelination and even axonal degeneration. In children, abnormal gait as a first sign of muscle weakness is a frequent reason to seek medical attention. Diagnosis is made on the basis of clinical characteristics, electromyography and nerve conduction studies, and elevated protein in cerebrospinal fluid. AIMS We present three new cases of CIDP. The literature was reviewed in order to obtain more information on presentation, outcome and treatment strategies world-wide. RESULTS The course of disease can be relapsing-remitting or chronic-progressive. From case series it is known that first-line immunotherapy (intravenously administered immunoglobulin, corticosteroids or plasmapheresis) is initially of benefit in most children with CIDP. There is little evidence, however, on second-line therapies as azathioprine, cyclosporine A, mycophenolate mofetil, methothrexate, cyclophosphamide and IFN alpha. Although the outcome of children with CIDP is generally regarded to be good, disease related disability can be severe. CONCLUSION Childhood CIDP is rare. In general and in comparison to adults, children tend to have a more acute progressive onset, with more severe symptoms. Showing a higher tendency towards a relapsing-remitting course, children often show a better and faster improvement after therapy, and a more favorable outcome. Swift recognition of CIDP and empiric start of treatment are considered important to avoid potentially irreversible axonal damage and associated disability. Response to first-line therapies is usually favorable, however recommendations regarding the choice of second-line therapy can only be made on the basis of current practice described in case reports. Safety and efficacy data are insufficient. The cases described show that trial and error are often involved in finding an optimal treatment strategy, especially in those patients refractory to first-line treatment or with a prolonged course. Clinical experience with immunomodulatory treatment is paramount when treating children with CIDP.
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Affiliation(s)
- Antoinetta G M Riekhoff
- Department of Neurology - Child Neurology, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Antwerp, Belgium.
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Concurrent chronic motor axonal polyneuropathy and synaptic impairment of neuromuscular junction. J Clin Neuromuscul Dis 2012; 12:223-6. [PMID: 22361520 DOI: 10.1097/cnd.0b013e3181df2b18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Polyneuropathies may exhibits clinical, electrophysiologic signs of neuromuscular junction impairment. Distal motor nerve terminals and neuromuscular junction contain pre or postsynaptically specific targets for circulating autoantibodies, if present in neuropathies. Motor nerve terminal blockade either reversible or permanent is a putative factor of muscle weakness. A 59-year-old patient exhibited oropharyngeal, facial, extremity weakness, fluctuating fatigability, and areflexia. Elecectrophysiologic studies showed purely motor axonal polyneuropathy. Thenar, facial slow rate repetitive stimulation revealed up to 47% decrement of compound muscle action potential size. Single fiber electromyography on voluntary activation confirmed increased jitter and impulse blocking in all muscles examined in one third of the fibers. Repeated testings for antibodies to gangliosides, acetylcholine, muscle tyrosine kinase receptors, voltage-gated calcium channels were negative. Oral pyridostigmine bromide improved bulbar symptoms. Pulse intravenous immunoglobulin, oral steroids, and azathioprine had steady benefit. Impairment of neuromuscular transmission if occurring in chronic axonal neuropathies highlights mechanisms and significance of neuromuscular chronic "synaptopathies."
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Cimaz R, Gana S, Braccesi G, Guerrini R. Sydenham's chorea in a girl with juvenile idiopathic arthritis treated with anti-TNFalpha therapy. Mov Disord 2010; 25:511-4. [PMID: 20014056 DOI: 10.1002/mds.22923] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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Sommer N, Tackenberg B, Hohlfeld R. The immunopathogenesis of myasthenia gravis. HANDBOOK OF CLINICAL NEUROLOGY 2008; 91:169-212. [PMID: 18631843 DOI: 10.1016/s0072-9752(07)01505-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Norbert Sommer
- Clinical Neuroimmunology Group, Philipps-University, Marburg, Germany
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Rentzos M, Anyfanti C, Kaponi A, Pandis D, Ioannou M, Vassilopoulos D. Chronic inflammatory demyelinating polyneuropathy: A 6-year retrospective clinical study of a hospital-based population. J Clin Neurosci 2007; 14:229-35. [PMID: 17258131 DOI: 10.1016/j.jocn.2006.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Accepted: 11/24/2006] [Indexed: 11/26/2022]
Abstract
We reviewed the clinical, electrophysiological, laboratory and neuroimaging features of 25 patients with chronic inflammatory demyelinating polyneuropathy (CIDP) admitted to Aeginition Hospital from 1996 to 2001. We also investigated the response to several treatment modalities. The aim was to reveal the clinical spectrum of the disease; the diagnostic criteria developed by the Ad Hoc Subcommittee of the American Academy of Neurology (AAN) in 1991 were used. The subjects consisted of 17 men (68%) and eight women (32%) aged 18-81 years (mean age: 48.5 years) with CIDP. Eighteen patients (72%) had a symmetric neuropathy, whereas seven (28%) had an asymmetric neuropathy. Two patients (8%) had a pure sensory neuropathy. Nine (36%) presented with cranial nerve involvement and only one (4%) had central nervous system demyelination. Most patients had a satisfactory response after treatment with corticosteroids, intravenous immunoglobulins, plasma exchange and azathioprine. In conclusion, CIDP is a clinically heterogeneous disorder. It is one of the few serious chronic neuropathies that has a good (although not permanent) treatment response.
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Affiliation(s)
- M Rentzos
- Department of Neurology, Aeginition Hospital, Athens Medical School, Vass. Sophias av. 72-74, 11528, Athens, Greece.
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Samuraki M, Furui E, Komai K, Takamori M, Yamada M. Myasthenia gravis presenting with unusual neurogenic muscle atrophy. Muscle Nerve 2007; 36:394-9. [PMID: 17326121 DOI: 10.1002/mus.20757] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We report a patient with myasthenia gravis who had neurogenic muscle atrophy in association with external ophthalmoplegia and weakness of the upper limbs. Neurogenic changes in the limb muscles were found on needle electromyography and histological studies. Symptoms improved and atrophy of the limbs diminished after intravenous immunoglobulin and oral corticosteroid therapy. We concluded that functional interruption of the neuromuscular junction caused the neurogenic muscle atrophy and that this was relieved by appropriate therapy.
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Affiliation(s)
- Miharu Samuraki
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Science, 13-1, Takaramachi, Kanazawa, Ishikawa 920-8640, Japan.
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Mori M, Kuwabara S, Nemoto Y, Tamura N, Hattori T. Concomitant chronic inflammatory demyelinating polyneuropathy and myasthenia gravis following cytomegalovirus infection. J Neurol Sci 2005; 240:103-6. [PMID: 16236323 DOI: 10.1016/j.jns.2005.08.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2005] [Revised: 08/26/2005] [Accepted: 08/29/2005] [Indexed: 11/18/2022]
Abstract
We describe a patient who concomitantly developed chronic inflammatory demyelinating polyneuropathy (CIDP) and myasthenia gravis (MG) following cytomegalovirus (CMV) infection. Whereas CIDP and MG presumably have different immunopathogeneses, a number of reports presented cases with CIDP and MG, some of which were concomitant cases. Several reports described association between CIDP or MG, and CMV infection, although the association is still a matter of controversy. This is the first report of patients with concomitant CIDP and MG following CMV infection. The association may be coincidental, but the possibility that CMV infection triggered development of both CIDP and MG simultaneously cannot be excluded.
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Affiliation(s)
- Masahiro Mori
- Department of Neurology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670 Japan.
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Farah R, Farah R, Simri W. Acute motor sensory axonal Guillain-Barre syndrome and myasthenia gravis. Eur J Intern Med 2005; 16:134-135. [PMID: 15833684 DOI: 10.1016/j.ejim.2005.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2004] [Accepted: 01/17/2005] [Indexed: 11/28/2022]
Affiliation(s)
- Raymond Farah
- Emergency Department, Nahariya Hospital, B. Rappaport Faculty of Medicine, Technion, Western Galilee Hospital-Nahariya, P.O. Box 21, Nahariya 22100, Israel
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Kitzmann KM, Gaylord NK, Holt AR, Kenny ED. Child witnesses to domestic violence: a meta-analytic review. J Consult Clin Psychol 2003; 71:339-52. [PMID: 12699028 DOI: 10.1037/0022-006x.71.2.339] [Citation(s) in RCA: 590] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This meta-analysis examined 118 studies of the psychosocial outcomes of children exposed to interparental violence. Correlational studies showed a significant association between exposure and child problems (d = -0.29). Group comparison studies showed that witnesses had significantly worse outcomes relative to nonwitnesses (d = -0.40) and children from verbally aggressive homes (d = -0.28). but witnesses' outcomes were not significantly different from those of physically abused children (d = 0.15) or physically abused witnesses (d = 0.13). Several methodological variables moderated these results. Similar effects were found across a range of outcomes, with slight evidence for greater risk among preschoolers. Recommendations for future research are made, taking into account practical and theoretical issues in this area.
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Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) in children is relatively rare. However, it has been recognized for many years. In patients presenting with this disease, subacute onset of weakness usually develops over at least 2 months and often progresses to a loss of ambulation. Some children's initial presentations may mimic Guillain-Barré syndrome. Dysasthesias are common. Males are affected more than females, and antecedent illnesses or vaccinations occur in approximately half of patients. Physical examination reveals diffuse, proximal greater than distal weakness, with an absence or depression of muscle stretch reflexes. Electrophysiology confirms demyelination, and spinal fluid examination demonstrates albuminocytologic dissociation. The clinical presentation, diagnosis, and prognosis of childhood CIDP are reviewed. Treatment and immunologic features are also discussed in this article.
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Affiliation(s)
- A M Connolly
- Department of Neurology, St. Louis Children's Hospital, Washington University of Medicine, St. Louis, Missouri 63110, USA
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Tsao CY, Mendell JR, Lo WD, Luquette M, Rennebohm R. Myasthenia gravis and associated autoimmune diseases in children. J Child Neurol 2000; 15:767-9. [PMID: 11108515 DOI: 10.1177/088307380001501113] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Myasthenia gravis has been associated with other autoimmune disorders. We report two children with myasthenia gravis and another autoimmune disease: an 18-month-old boy with ocular myasthenia gravis and Hashimoto's disease and a 14-year-old girl presenting with autoimmune polymyositis, then generalized myasthenia gravis 2 years later. The rare combinations of myasthenia gravis and Hashimoto's disease or polymyositis in children are discussed, and we also briefly review myasthenia gravis and other associated autoimmune diseases in children.
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Affiliation(s)
- C Y Tsao
- Department of Pediatrics, College of Medicine and Public Health, Ohio State University, Columbus, USA
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