Semin Neurol 2004; 24(1): 101-110
DOI: 10.1055/s-2004-829591
Copyright © 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Autoimmune Myasthenia Gravis in Childhood

P. Ian Andrews1
  • 1Senior Lecturer in Paediatrics, University of New South Wales, and Paediatric Neurologist, Sydney Children's Hospital, Australia
Further Information

Publication History

Publication Date:
01 July 2004 (online)

The recent identification of an autoimmune process targeting muscle-specific kinase (MuSK) in a subset of seronegative patients with autoimmune myasthenia gravis promises to improve diagnostic accuracy and redirect therapy in at least some seronegative children and adolescents with myasthenia. Clinical features, diagnostic methods, and management strategies pertinent to children with autoimmune myasthenia are discussed, as well as the emerging data regarding the anti-MuSK autoimmune process in myasthenia gravis.

REFERENCES

  • 1 Willis T. De Anima Brutorum. In: Portage S Two Discourses Concerning the Soul of Brutes. Translated by Pordage S. London, 1683 Oxford; Theatro Sheldoniano 1672
  • 2 Erb W. Zur casuistik der bulbaren lahmungen. (3) Ueber einen neuen, wahrscheinlich bulbaren symptomencomplex.  Arch Psychiatr Nervenkr. 1879;  9 336-350
  • 3 Kandel E R, Siegelbaum S A. Signaling at the nerve-muscle synapse: directly gated transmission. In: Kandel ER, Schwartz JH, Jessell TM Principals of Neuroscience, 4th ed. New York; McGraw-Hill 2000: 187-206
  • 4 Sanes J R, Jessell T M. The formation and generation of synapses. In: Kandel ER, Schwartz JH, Jessell TM Principals of Neuroscience, 4th ed. New York; McGraw-Hill 2000: 1087-1114
  • 5 Sanes J R, Lichtman J W. Development of the vertebrate neuromuscular junction.  Annu Rev Neurosci. 1999;  22 389-442
  • 6 Fidzianska A. Human ontogenesis II: development of the human neuromuscular junction.  J Neuropathol Exp Neurol. 1980;  39 606-615
  • 7 Hesselmans L FGM, Jennekens F GI, van den Ord C JM, Oestreicher A B, Gispen W H. A light and electron microscopical study of B-50 (GAP-43) in human intramuscular nerve and neuromuscular junctions during development.  J Neurol Sci. 1989;  89 301-311
  • 8 Hoch W, McConville J, Helms S, Newsom-Davis J, Melms A, Vincent A. Auto-antibodies to the receptor tyrosine kinase MuSK in patients with myasthenia gravis without acetylcholine receptor antibodies.  Nat Med. 2001;  7 365-368
  • 9 Evoli A, Tonali P A, Padua L et al.. Clinical correlates with anti-MuSK antibodies in generalized seronegative myasthenia gravis.  Brain. 2003;  126 2304-2311
  • 10 Vincent A, Bowen J, Newsom-Davis J, McConville J. Seronegative generalised myasthenia gravis: clinical features, antibodies, and their targets.  Lancet Neurol. 2003;  2 99-106
  • 11 Sanders D B, El-Salem K, Massey J M, McConville J, Vincent A. Clinical aspects of MuSK antibody positive seronegative MG.  Neurology. 2003;  60 1978-1980
  • 12 Sanders D B, Andrews P I, Howard Jr J F, Massey J M. Seronegative myasthenia gravis.  Neurology. 1997;  48(suppl 5) S40-S45
  • 13 Yoshikawa H, Lennon V A. Acetylcholine receptor autoantibody secretion by thymocytes: relationship to myasthenia gravis.  Neurology. 1997;  49 562-567
  • 14 Yamamoto T, Vincent A, Ciulla T A, Lang B, Johnston I, Newsom-Davis J. Seronegative myasthenia gravis: a plasma factor inhibiting agonist-induced acetylcholine receptor function copurifies with IgM.  Ann Neurol. 1991;  30 550-557
  • 15 Plested C P, Tang T, Spreadbury I, Littleton E T, Kishore U, Vincent A. AChR phosphorylation and indirect inhibition of AChR function in seronegative MG.  Neurology. 2002;  59 1682-1688
  • 16 Bufler J, Pitz R, Czep M, Wick M, Francke C. Purified IgG from seropositive and seronegative patients with myasthenia gravis reversibly blocks currents through nicotinic acetylcholine receptor channels.  Ann Neurol. 1998;  43 458-464
  • 17 Drachman D B. Myasthenia gravis: a model disorder of acetylcholine receptors.  Res Publ Assoc Res Nerv Ment Dis. 1987;  65 65-82
  • 18 Soliven B C, Lange D J, Penn A S et al.. Seronegative myasthenia gravis.  Neurology. 1988;  38 514-516
  • 19 Evoli A, Bartoccioni E, Bartocchi A P, Scuderi F, Tonali P. Anti-AchR negative myasthenia gravis: clinical and immunological features.  Clin Invest Med. 1989;  12 104-109
  • 20 Karni A, Zisman E, Katz-Levy Y et al.. Reactivity of T cells from seronegative myasthenia gravis to T cell epitopes of the human acetylcholine receptor.  Neurology. 1997;  48 1638-1642
  • 21 Lu C Z, Lu L, Hao Z S, Xia D G, Qain J, Arnason B G. Antibody-secreting cells to acetylcholine receptor and to presynaptic membrane receptor in seronegative myasthenia gravis.  J Neuroimmunol. 1993;  43 145-149
  • 22 Ragheb S, Lisak R P. Immune regulation and myasthenia gravis.  Ann N Y Acad Sci. 1998;  841 210-224
  • 23 Drachman D B. Medical progress: myasthenia gravis.  N Engl J Med. 1994;  330 1797-1810
  • 24 Geh V S, Bradbury J A. Ocular myasthenia presenting in an 11-month-old boy.  Eye. 1998;  12 319-320
  • 25 Phillips L H, Torner J C, Anderson M S, Cox G M. The epidemiology of myasthenia gravis in central and western Virginia.  Neurology. 1992;  42 1888-1893
  • 26 Andrews P I, Massey J M, Howard J FJ, Sanders D B. Race, sex, and puberty influence onset, severity, and outcome in juvenile myasthenia gravis.  Neurology. 1994;  44 1208-1214
  • 27 Evoli A, Batocchi A P, Bartoccioni E, Lino M M, Minisci C, Tonali P. Juvenile myasthenia gravis with prepubertal onset.  Neuromuscul Disord. 1998;  8 561-567
  • 28 Batocchi A P, Evoli A, Palmisani M T, Lo Monaco M, Bartoccioni M, Tonali P. Early-onset myasthenia gravis: clinical characteristics and response to therapy.  Eur J Pediatr. 1990;  150 66-68
  • 29 Uono M. Clinical statistics of myasthenia gravis in Japan.  Int J Neurol. 1980;  14 87-99
  • 30 Chiu H C, Newsom-Davis J, Hsieh K H, Hung T. Myasthenia gravis: population differences in disease expression and acetylcholine receptor antibody titers between Chinese and Caucasians.  Neurology. 1987;  37 1854-1857
  • 31 Osserman K E. Myasthenia Gravis. New York; Grune & Stratton 1958
  • 32 Walsh F B, Hoyt W F. Chapter 9: Disorders of muscle. Clinical Ophthalmology. Baltimore; Williams & Wilkins 1969: 1242-1311
  • 33 Brodsky M C, Baker R S, Hamed L M. Pediatric Neuro-ophthalmology. New York; Springer 1996
  • 34 Cogan D G. Myasthenia gravis: a review of the disease and a description of lid twitch as a characteristic sign.  Arch Ophthalmol. 1965;  74 217-221
  • 35 Linder A, Schalke B, Toyka K V. Outcome in juvenile-onset myasthenia gravis: a retrospective study with long-term follow-up of 79 patients.  J Neurol. 1997;  244 515-520
  • 36 Rodriguez M, Gomez M R, Howard Jr F M, Taylor W F. Myasthenia gravis in children: long-term follow-up.  Ann Neurol. 1983;  13 504-510
  • 37 Fukuyama Y, Suzuki M, Segawa M. Studies on myasthenia gravis in childhood.  Paediatr Univ Tokyo. 1970;  18 57-68
  • 38 Wong V, Hawkins B R, Yu Y L. Myasthenia gravis in Hong Kong Chinese. 2. Paediatric disease.  Acta Neurol Scand. 1992;  86 68-72
  • 39 Grob D, Arsura E L, Brunner N G, Namba T. The course of myasthenia gravis and therapies affecting outcome.  Ann N Y Acad Sci. 1987;  505 472-499
  • 40 Snead O C, Benton J W, Dwyer D et al.. Juvenile myasthenia gravis.  Neurology. 1980;  30 732-739
  • 41 Okun M S, Charriez C M, Bhatti M T et al.. Asystole induced by edrophonium following beta blockade.  Neurology. 2001;  57 739-740
  • 42 Afifi A K, Bell W E. Tests for juvenile myasthenia gravis: comparative diagnostic yield and prediction of outcome.  J Child Neurol. 1993;  8 403-411
  • 43 Younger D S, Worrall B B, Penn A S. Myasthenia gravis: historical perspective and overview.  Neurology. 1997;  48(suppl 5) S1-S7
  • 44 Lennon V A. Serological diagnosis of myasthenia gravis and the Lambert-Eaton myasthenic syndrome. In: Lisak RP Handbook of Myasthenia Gravis and Myasthenic Syndromes. New York; Marcel Dekker 1994: 149-164
  • 45 Andrews P I, Massey J M, Sanders D B. Acetylcholine receptor antibodies in juvenile myasthenia gravis.  Neurology. 1993;  43 977-982
  • 46 Sanders D B, Stålb erg E V. AAEM Minimonograph #25: single-fiber electromyography.  Muscle Nerve. 1996;  19 1069-1083
  • 47 Gajdos P, Chevret S, Clair B, Tranchant C, Chastang C. Plasma exchange and intravenous immunoglobulin in autoimmune myasthenia gravis.  Ann N Y Acad Sci. 1998;  841 720-726
  • 48 Lewis R A, Selwa J F, Lisak R P. Myasthenia gravis: immunological mechanisms and immunotherapy.  Ann Neurol. 1995;  37(suppl 1) S51-S62
  • 49 Edan G, Landgraf F. Experience with intravenous immunoglobulin in myasthenia gravis: a review.  J Neurol Neurosurg Psychiatry. 1994;  57(suppl) 55-56
  • 50 Evoli A, Palmisani M T, Bartoccioni E, Padua L, Tonali P. High-dose intravenous immunoglobulin in myasthenia gravis.  Ital J Neurol Sci. 1993;  14 233-237
  • 51 Stricker R B, Kwiatkowska B J, Habis J A, Kiprov D D. Myasthenic crisis. Response to plasmapheresis following failure of intravenous gamma globulin.  Arch Neurol. 1993;  50 837-840
  • 52 Fasano M B. Risks and benefits of intravenous immunoglobulin treatment in children.  Curr Opin Pediatr. 1995;  7 688-694
  • 53 Brannagan T H, Nagle K J, Lange D J, Rowland L P. Complications of intravenous immune globulin treatment in neurologic disease.  Neurology. 1996;  47 674-677
  • 54 Badurska B, Ryniewicz B, Strugalska H. Immunosuppressive treatment for juvenile myasthenia gravis.  Eur J Pediatr. 1992;  151 215-217
  • 55 Arsura E, Brunner N G, Namba T, Grob D. High-dose intravenous methylprednisolone in myasthenia gravis.  Arch Neurol. 1985;  42 1149-1153
  • 56 Sakano T, Hamasaki T, Kinoshita Y, Kihara M, Ueda K. Treatment for refractory myasthenia gravis.  Arch Dis Child. 1989;  64 1191-1193
  • 57 Tanaka J, Matsuzaki K, Arai H, Nagai T, Matsumoto Y, Okada S. Intermittent methylprednisolone pulse therapy for myasthenia gravis in childhood.  No To Hattatsu. 1994;  26 14-19
  • 58 Bocanegra T S, Castaneda M O, Espinoza L R, Vasey F B, Germain B F. Sudden death after methylprednisolone pulse therapy.  Ann Intern Med. 1981;  95 122
  • 59 McLuckie A E, Savage R W. Atrial fibrillation following pulse methylprednisolone therapy in an adult.  Chest. 1993;  104 622-623
  • 60 Panegyres P K, Squier M, Mills K R, Newsom-Davis J. Acute myopathy associated with large parenteral dose of corticosteroid in myasthenia gravis.  J Neurol Neurosurg Psychiatry. 1993;  56 702-704
  • 61 Andrews P I. A treatment algorithm for autoimmune myasthenia gravis in childhood.  Ann N Y Acad Sci. 1998;  841 789-802
  • 62 Seybold M E. Thymectomy in childhood myasthenia gravis.  Ann N Y Acad Sci. 1998;  841 731-741
  • 63 Evoli A, Batocchi A P, Lo Monaco M et al.. Clinical heterogeneity of seronegative myasthenia gravis.  Neuromuscul Disord. 1996;  6 155-161
  • 64 Verma P K, Oger J J. Seronegative generalized myasthenia gravis: low frequency of thymic pathology.  Neurology. 1992;  42 586-589
  • 65 Blossom G B, Ernstoff R M, Howells G A, Bendick P J, Glover J L. Thymectomy for myasthenia gravis.  Arch Surg. 1993;  128 855-862
  • 66 Frist W H, Thirumalai S, Doehring C B. Thymectomy for the myasthenia gravis patient: factors influencing outcome.  Ann Thorac Surg. 1994;  57 334-338
  • 67 Seybold M E, Howard F M, Duane D D, Payne W S, Harrison E G. Thymectomy in juvenile myasthenia gravis.  Arch Neurol. 1971;  25 385-392
  • 68 Campbell J R, Bisio J M, Harrison M W, Campbell T J. Surgical treatment of myasthenia gravis in childhood.  J Pediatr Surg. 1983;  18 857-861
  • 69 Keynes G, Camb M D. Surgery of the thymus gland.  Lancet. 1954;  1 1197-1202
  • 70 Brearley S, Gentle T A, Baynham M I, Roberts K D, Abrams L D, Thompson R A. Immunodeficiency following neonatal thymectomy in man.  Clin Exp Immunol. 1987;  70 322-327
  • 71 Ramos S B, Garcia A B, Viana S R, Voltarelli J C, Falcao R P. Phenotypic and functional evaluation of natural killer cells in thymectomized children.  Clin Immunol Immunopathol. 1996;  81 277-281
  • 72 Rubinstein A, Pelet B, Schweizer V. Immunological decay in thymectomized infants.  Helv Paediatr Acta. 1976;  30 425-433
  • 73 Wells W J, Parkman R, Smogorzewska E, Barr M. Neonatal thymectomy: does it affect immune function?.  J Thorac Cardiovasc Surg. 1998;  115 1041-1046
  • 74 Masaoka A, Yamakawa Y, Niwa H et al.. Extended thymectomy for myasthenia gravis patients: a 20-year review.  Ann Thorac Surg. 1996;  62 853-859
  • 75 Nakamura H, Taniguchi Y, Suzuki Y et al.. Delayed remission after thymectomy for myasthenia gravis of the purely ocular type.  J Thorac Cardiovasc Surg. 1996;  112 371-375
  • 76 Schumm F, Wietholter H, Fateh-Moghadam A, Dichgans J. Thymectomy in myasthenia with pure ocular symptoms.  J Neurol Neurosurg Psychiatry. 1985;  48 332-337
  • 77 Wilkins K B, Bulkley G B. Thymectomy in the integrated management of myasthenia gravis.  Adv Surg. 1999;  32 105-133
  • 78 Sanders D B, Howard J F, Johns T R, Campa J F. High-dose daily prednisone in the treatment of myasthenia gravis. In: Dau PC Plasmapheresis and the Immunobiology of Myasthenia Gravis. Boston; Houghton-Mifflin 1979: 289-306
  • 79 Pascuzzi R M, Coslett B, Johns T R. Long-term corticosteroid treatment of myasthenia gravis: report of 116 patients.  Ann Neurol. 1984;  15 291-298
  • 80 Kupersmith M J, Moster M, Bhuiyan S, Warren F, Weinberg H. Beneficial effects of corticosteroids on ocular myasthenia gravis.  Arch Neurol. 1996;  53 802-804
  • 81 Lindberg C, Andersen O, Larsson S, Oden A. Remission rate after thymectomy in myasthenia gravis when the bias of immunosuppressive therapy is eliminated.  Acta Neurol Scand. 1992;  86 323-328
  • 82 Kerribjin K F, De Kroon P M. Effect on height of corticosteroid therapy in asthmatic children.  Arch Dis Child. 1968;  43 556-561
  • 83 Rees L, Greene S A, Adlard P et al.. Growth and endocrine function in steroid sensitive nephrotic syndrome.  Arch Dis Child. 1988;  63 484-490
  • 84 Lettgen B, Jeken C, Reiners C. Influence of steroid medication on bone mineral density in children with nephrotic syndrome.  Pediatr Nephrol. 1994;  8 667-670
  • 85 Palace J, Newsom-Davis J, Lecky B. The Myasthenia Gravis Study Group . A randomized double-blind trial of prednisolone alone or with azathioprine in myasthenia gravis.  Neurology. 1998;  50 1778-1783
  • 86 Cosi V, Lombardi M, Erbetta A, Piccolo G. Azathioprine as a single immunosuppressive drug in the treatment of myasthenia gravis.  Acta Neurol (Napoli). 1993;  15 123-131
  • 87 Confavreux C, Saddier P, Grimaud J, Moreua T H, Adeleine P, Aimard G. Risk of cancer from azathioprine therapy in multiple sclerosis.  Neurology. 1996;  46 1607-1612
  • 88 Evoli A, Batocchi A P, Tonali P, Marciano M. Risk of cancer in patients with myasthenia gravis.  Ann N Y Acad Sci. 1998;  841 742-745
  • 89 Tindall R SA, Phillips J T, Rollins J A, Wells L, Hall K. A clinical therapeutic trial of cyclosporine in myasthenia gravis.  Ann N Y Acad Sci. 1993;  681 539-551
  • 90 Ciafaloni E, Nikhar N K, Massey J M, Sanders D B. Retrospective analysis of the use of cyclosporine in myasthenia gravis.  Neurology. 2000;  55 448-450
  • 91 Hauser R A, Malek A R, Rosen R. Successful treatment of a patient with severe refractory myasthenia gravis using mycophenolate mofetil.  Neurology. 1998;  51 912-913
  • 92 Ciafaloni E, Massey J M, Sanders D B. An open label trial of mycophenolate mofetil in myasthenia gravis.  Neurology. 2001;  56 97-99

P. I AndrewsM.B.B.S. 

Division of Neurology, Sydney Children's Hospital

High Street, Randwick 2031, Australia

    >