Myasthenia gravis is characterized by episodic muscle weakness and easy fatigability caused by autoantibody- and cell-mediated destruction of acetylcholine receptors. It is more common among young women and older men but may occur in men or women at any age. Symptoms worsen with muscle activity and lessen with rest. Diagnosis is by measurement of serum acetylcholine receptor (AChR) antibody levels, electromyography, and bedside tests (ice pack test, rest test). Treatment includes anticholinesterase medications, immunosuppressants, plasma exchange, IV immune globulin, and possibly thymectomy.
(See also Overview of Peripheral Nervous System Disorders.)
Myasthenia gravis develops most commonly in women aged 20 to 40 and men aged 50 to 80, but it can occur at any age, including childhood (1).
Myasthenia gravis results from an autoimmune attack on postsynaptic acetylcholine receptors, which disrupts neuromuscular transmission. The trigger for autoantibody production is unknown, but the disorder is associated with abnormalities of the thymus, autoimmune hyperthyroidism, and other autoimmune disorders (eg, rheumatoid arthritis [RA], systemic lupus erythematosus [SLE], pernicious anemia).
The role of the thymus in myasthenia is unclear, but 65% of patients have thymic hyperplasia, and 10% have a thymoma (2). About half of the thymomas are malignant.
Precipitating factors for myasthenia gravis include
Infection
Surgery
Abnormal antibodies
Most patients with myasthenia gravis develop antibodies to acetylcholine receptors (AChRs); these antibodies bind to AChRs on the postsynaptic membrane at the neuromuscular junction and interrupt neuromuscular transmission. About 10 to 20% of patients with generalized myasthenia have no antibodies to acetylcholine receptors (AChR) in serum. Up to 70% of these AChR antibody‒negative patients have antibodies to muscle-specific receptor tyrosine kinase (MuSK), a surface membrane enzyme that helps AChR molecules aggregate during development of the neuromuscular junction (3). However, anti-MuSK antibodies do not occur in most patients with AChR antibodies or with isolated ocular myasthenia.
The clinical significance of anti-MuSK antibodies is still under study, but patients with these antibodies are much less likely to have thymic hyperplasia or a thymoma, may be less responsive to anticholinesterase medications, and may require more aggressive early immunotherapy than patients who have AChR antibodies.
Uncommon forms
Ocular myasthenia gravis involves only extraocular muscles. It represents about 15% of cases.
Congenital myasthenia is a rare autosomal recessive disorder that begins in childhood. It is not immune-mediated and results from presynaptic or postsynaptic abnormalities, including the following:
Reduced acetylcholine resynthesis due to choline acetyltransferase deficiency
End-plate acetylcholinesterase deficiency
Structural abnormalities in the postsynaptic receptor
Ophthalmoplegia is common in patients with congenital myasthenia.
Neonatal myasthenia affects approximately 10 to 15% of infants born to women with myasthenia gravis (4). It is due to IgG antibodies that passively cross the placenta. It causes generalized muscle weakness, which resolves in days to weeks as antibody titers decline. Thus, treatment is usually supportive.
General references
1. Carr AS, Cardwell CR, McCarron PO, McConville J: A systematic review of population based epidemiological studies in myasthenia gravis. BMC Neurol 18:10:46, 2010. doi: 10.1186/1471-2377-10-46
2. Estévez DAG, Fernández JP: Myasthenia gravis. Update on diagnosis and therapy. Med Clin (Barc) 161 (3):119–127, 2023. doi: 10.1016/j.medcli.2023.04.006 Epub 2023 May 27.
3. Hoch W, McConville J, Helms S, et al: Auto-antibodies to the receptor tyrosine kinase MuSK in patients with myasthenia gravis without acetylcholine receptor antibodies. Nat Med 7 (3):365–368, 2001. doi: 10.1038/85520
4. Bardhan M, Dogra H; Samanta. D: Neonatal myasthenia gravis. 2023. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–.
Symptoms and Signs of Myasthenia Gravis
The most common symptoms of myasthenia gravis are
Ptosis
Diplopia
Muscle weakness after use of the affected muscle
Weakness resolves when the affected muscles are rested but recurs when they are used again. Weakness due to myasthenia lessens in cooler temperatures.
Ocular muscles are affected initially in 40% of patients and eventually in 85% and are the only muscles affected in 15% (1). If generalized myasthenia is going to develop after ocular symptoms, it develops in 78% of patients within 1 year and in 94% within the first 3 years.
Hand grip may alternate between weak and normal (milkmaid’s grip). Neck muscles may become weak. Proximal limb weakness is common. Some patients present with bulbar symptoms (eg, altered voice, nasal regurgitation, choking, dysphagia). Sensation and deep tendon reflexes are normal. Manifestations fluctuate in intensity over minutes to hours to days.
Myasthenic crisis, a severe generalized quadriparesis or life-threatening respiratory muscle weakness, occurs in about 15 to 20% of patients at least once in their life (2). It is often due to a supervening infection that reactivates the immune system. Once respiratory insufficiency begins, respiratory failure may occur rapidly.
Cholinergic crisis
Symptoms and signs references
1. Kerty E, Elsais A, Argov Z, et al: EFNS/ENS [European Federation of Neurological Societies/European Neurological Society]. Guidelines for the treatment of ocular myasthenia. Eur J Neurol 21 (5):687–693, 2014. doi: 10.1111/ene.12359
2. Spillane J, Higham E, Kullmann DM: Myasthenia gravis. BMJ 345:e8497, 2012. doi: 10.1136/bmj.e8497
Diagnosis of Myasthenia Gravis
Bedside tests (ice pack test, rest test)
AChR antibody levels, electromyography, or both
The diagnosis of myasthenia gravis is suggested by symptoms and signs and confirmed by tests.
Bedside testing
The traditional anticholinesterase test, done at bedside and using the short-acting (< 5 minutes) medication edrophonium, is not used in the United States and in many other countries, and edrophonium is no longer available in the United States.
Because weakness due to myasthenia lessens in cooler temperature, patients with ptosis can be tested using the ice pack test. For this test, an icepack is applied to a patient's closed eyes for 2 minutes, then removed. A positive result is full or partial resolution of ptosis. Sensitivity may be about 80% (1). The ice pack test usually does not work if patients have ophthalmoparesis.
Patients with opthalmoparesis can be tested using the rest test. For this test, patients are asked to lie quietly in a dark room for 5 minutes with their eyes closed. If ophthalmoparesis resolves after this rest, the result is positive.
Antibody testing and electromyography
Even if a bedside test is unequivocally positive, one or both of the following are required to confirm the diagnosis:
Serum AChR antibody levels
Electromyography (EMG)
AChR antibodies are present in 80 to 90% of patients with generalized myasthenia but in only 50% with the ocular form. Antibody levels do not correlate with disease severity. Up to 50% of patients without AChR antibodies test positive for anti-MuSK antibodies (1).
EMG using repetitive stimuli (2 to 3/seconds) shows a > 10% decrease in amplitude of the compound muscle action potential response in 60% of patients (2). Single-fiber EMG can detect abnormal neuromuscular transmission in > 95% (3).
Further testing
Once myasthenia is diagnosed, CT or MRI of the thorax should be done to check for thymic hyperplasia and a thymoma.
Other tests should be done to screen for autoimmune disorders frequently associated with myasthenia gravis (eg, pernicious anemia, autoimmune hyperthyroidism, RA, SLE).
Patients in myasthenic crisis should be evaluated for an infectious trigger.
Bedside pulmonary function tests (eg, forced vital capacity) help detect impending respiratory failure.
Diagnosis references
1. Golnik KC, Pena R, Lee AG, Eggenberger ER: An ice test for the diagnosis of myasthenia gravis. Ophthalmology 106 (7):1282–1286. doi: 10.1016/S0161-6420(99)00709-5
2. Oh SJ, Kim DE, Kuruoglu R, et al: Diagnostic sensitivity of the laboratory tests in myasthenia gravis. Muscle Nerve 15 (6):720–724, 1992. doi: 10.1002/mus.880150616
3. Padua L, Caliandro P, Di Iasi G, et al: Reliability of SFEMG [single-fibre electromyography] in the diagnosis of myasthenia gravis} in diagnosing myasthenia gravis: sensitivity and specificity calculated on 100 prospective cases. Clin Neurophysiol 125 (6):1270–1273, 2014. doi: 10.1016/j.clinph.2013.11.005 Epub 2013 Nov.
Treatment of Myasthenia Gravis
Anticholinesterase medications to relieve symptoms
Immunosuppressants (eg, corticosteroids)
IV immune globulin [IVIG] or plasma exchange for acute exacerbations (including myasthenic crisis)
Sometimes thymectomy
Supportive care
In patients with congenital myasthenia, anticholinesterase medications and immunomodulating treatments are not beneficial and should be avoided. Patients with respiratory failure require intubation and mechanical ventilation.
Symptomatic treatment
Anticholinesterase medications are the mainstay of symptomatic treatment but do not alter the underlying disease process. Moreover, they rarely relieve all symptoms, and myasthenia may become refractory to these medications.
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Patients who have been responding well to treatment and then deteriorate require respiratory support because they may have cholinergic crisis, and anticholinesterase medications must be stopped for several days.
Immunomodulating treatment
1). Effects may last 1 to 2 months. Plasma exchange (eg, 5 exchanges of 3 to 5 L plasma over 7 to 14 days) can have similar effects.
Thymectomy may be indicated for patients with generalized myasthenia if they are < 65 years (2, 3); it should be done in all patients with a thymoma. Subsequently, in 80%, remission occurs or the maintenance medication dose can be lowered.
Plasma exchange or IVIG (the usual treatment for myasthenic crisis) may also be useful if patients are unresponsive to medications before thymectomy.
Treatment references
1. Barth D, Nouri MN, Ng E, et al: Comparison of IVIg and PLEX in patients with myasthenia gravis. Neurology 76 (23):2017–2023, 2011. doi: 10.1212/WNL.0b013e31821e5505 Epub 2011 May 11.
2. Gronseth GS, Barohn R, Narayanaswami P: Practice advisory: Thymectomy for myasthenia gravis (practice parameter update): Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 94 (16):705–709, 2020. doi: 10.1212/WNL.0000000000009294 Epub 2020 Mar 25.
3. Wolfe GI, Kaminski HJ, Aban IB, et al: Randomized trial of thymectomy in myasthenia gravis. N Engl J Med 375 (6):511–522, 2016.
Key Points
Consider myasthenia gravis in patients with ptosis, diplopia, and muscle weakness after use of the affected muscle.
To confirm the diagnosis, measure serum levels of AChR antibody (usually present in myasthenia gravis), do electromyography (EMG), or both.
After the diagnosis is confirmed, test for thymic hyperplasia, thymomas, hyperthyroidism, and autoimmune disorders, which commonly accompany myasthenia gravis.
For most patients, use anticholinesterase medications to relieve symptoms and immunomodulating treatment to slow disease progression and help relieve symptoms; do not use these treatments in patients with congenital myasthenia.
If patients have a myasthenic crisis, treat with IVIG or plasma exchange.
If patients suddenly deteriorate after responding well to treatment, provide respiratory support and stop anticholinesterase medications for several days because they may have cholinergic crisis.
