Myasthenia gravis

Czech version

Authors: Peter Špalek
Authors‘ workplace: Neurologická klinika SZU FNsP Bratislava-Ružinov
Published in: Cesk Slov Neurol N 2008; 71/104(1): 7-24
Category: Minimonography

Overview

Myasthenia gravis (MG) is defined as a disorder of the neuromuscular junction with fluctuating weakness of voluntary muscles associated with exhaustibility. The incidence of MG is 7,0 to14,8 cases per million population per year. The prevalence rate ranges from 80,0 to191,6 per million population. The most common age at onset of MG is the second and third decades in women, the sixth and seventh decades in men. MG is a heterogenous disorder with 4 distinct subgroups which differ immunologically, clinically and in responses to various treatments: A. 75 % MG patients have seropositive MG (SPMG) with autoantibodies against nicotinic acetylcholine receptor (AChR). B. 15 % MG patients have SPMG with autoantibodies to AChR associated with thymoma and antibodies against titine. C. 7 % MG patients have seronegative MG (SNMG) to AChR and positive antibodies against MuSK (muscle specific kinase). D. 8 % MG patients have „pure“ SNMG (no autoantibodies to AChR/MuSK). Diagnostic procedures in MG are clinical evaluation, intravenous administration of neostigmin/edrophonium, EMG (repetitive nerve stimulation, single fibre electromyography), autoantibodies to AChR, MuSK, titine; chest CT or chest MR (thymoma diagnosis). Treatment focuses on anticholinesterases, immunosuppressive agents, thymectomy, and short-term interventions such as plasmapheresis, immunoadsorption and intravenous immunoglobulin (IVIg). These treatments, usually in combination, produce remission or improvement in about 90 % of MG patients. Refractory cases to immunosuppressive therapy may improve with plasmapheresis or IVIg on chronic intermittent basis. Treatment should be individualized and there is no single regimen that is appropriate for all patients.

Key words:
myasthenia gravis – neuromuscular junction – pathophysiology – imunopathogenesis – diagnosis – management – prognosis

Sources

1. Hughes T. The early history of myasthenia gravis. Neuromusc Dis 2005; 15: 878

886.

2. Šmat V, Schutzner J. Historie léčby myasthenia gravis. In: Schutzner J, Šmat V et al. Myasthenia gravis – komplexní pojetí a chirurgická léčba. Praha: Galén 2005: 11-17.

3. Oosterhuis HJGH. Myasthenia gravis. Groningen: Neurological Press 1997.

4. Gooch CL. Myasthenia gravis and Lambert-Eaton myasthenic syndrome. In: Rolak LA, Harati Y. Neuroimmunology for the clinician. Newton: Butterworth-Heinemann 1997: 263-299.

5. Warmolts JR, Engel WK. Benefit from alternate-day prednisone in myasthenia gravis. N Engl J Med 1972; 286: 17-19.

6. Nouza K, Šmat V. The favorable effect of cyclophosphamide in myasthenia gravis.

Rev franc clin biol 1968; 13: 161-163.

7. Mertens HG, Balzereit F, Leipert M. The treatment of severe myasthenia gravis with immunosuppressive agents. Eur Neurol 1969; 2: 323-339.

8. Pinching AJ, Peters DK, Newsom-Davis J. Remission of myasthenia gravis following plasma exchange. Lancet 1976; 2: 1373-1374.

9. Špalek P. Myasthenia gravis – register a epidemiológia na Slovensku. Diagnostický význam stapediovej reflexometrie. Analýza účinnosti imunologických foriem liečby. Kandidátska dizertačná práca. Bratislava: LF Univerzity Komenského 1983.

10. Špalek P, Lisý Ľ. Myasthenia gravis – liečba Prednizonom. Čs Neurol Neurochir 1982; 45/78: 418-424.

11. Hoch W, McConville J, Helms S, Newsom-Davis J, Melms A, Vincent A. Autoantibodies to the receptor tyrosine kinase MuSK in patients with myasthenia gravis without acetylcholine receptor antibodies. Nat Med 2001; 7: 365-368.

12. Špalek P. Myasténia gravis a autoprotilátky – dlhý a nekončiaci sa príbeh. Čes Slov Neurol Neurochir (editorial). V tlači 2008.

13. Engel AG. Anatomy and molecular architecture of the neuromuscular junction. In: Engel AG. Myasthenia gravis and myasthenic disorders. Oxford: University Press 1999: 3-39.

14. Kaminski HJ, Ruff RL. Structure and kinetic properties of the acetylcholine receptor. In: Engel AG. Myasthenia gravis and myasthenic disorders. Oxford: University Press 1999: 40-64.

15. Molenaar P. Synthesis, storage and release of acetylcholine. In: Vincent A, Wray D. Neuromuscular transmission – basic and applies aspects. Manchester: University Press 1990; 62-81.

16. Vincent A. Immunology of disorders of neuromuscular transmission. Acta Neurol. Scand. 2006; 183 (Suppl.): 1-7.

17. Newsom-Davis J. The emerging diversity of neuromuscular junction disorders. Acta Myol 2007; 16: 5-10.

18. Špalek P, Vincent A. Autoantibodies at the neuromuscular junction. Neurológia (Bratisl) 2007; 2 (Suppl. 1): 11-12.

19. Špalek P. Ochorenia nervovosvalového prenosu. In: Rovenský J et al. Reumatológia v teórii a praxi. Martin: Osveta 1998: 651-659.

20. Sanders DB, Andrews PI, Barohn RJ, Massey JM, Phillips LH. Myasthenia gravis. Hagerstown, Baltimore: Lippincott Wiliams Wilkins 1999.

21. Špalek P. Diagnostika a liečba ochorení neuromuskulárnej transmisie a primárne myogénnych ochorení. Habilitačná práca. Bratislava: LF University Komenského 1990.

22. Fambrough DM, Drachman DB, Satyamurti S. Neuromuscular junction in myasthenia gravis: decreased acetylcholine receptors. Science 1973; 182: 293-295.

23. Engel AG, Tsujihata M, Sakakibara H, Lindstrom J, Lambert EH. Ultrastucture evidence for acetylcholine receptor dysfunction in myasthenia gravis and its autoimmune model. In: Rowland LM. Pathogenesis of human muscular dystrophies. Amsterdam: Elsevier 1977: 133-142.

24. Patrick J, Lindstrom J. Autoimmunity response to acetylcholine receptor. Science 1973; 180: 871-872.

25. Lindstrom JM. Experimental autoimmune myasthenia gravis: induction and treatment. In: Engel AG. Myasthenia gravis and myasthenic syndromes. Oxford: University Press 1999: 65-86.

26. Newsom-Davis J, Beeson D. Myasthenia gravis and myasthenic syndromes: autoimmune and genetic disorders. In: Karpati G, Hilton-Jones D, Griggs RC. Disorders of voluntary muscles. Cambridge: University Press 2001: 660-672.

27. Lindstrom JM, Seybold ME, Lennon VA, Wittingham S, Duane DD. Antibody to acetylcholine receptor in myasthenia gravis. Neurology 1976; 26: 1054-56.

28. Kuks JBM. The thymus and myasthenia gravis. Doctoral thesis. Groningen: University of Groningen 1992.

29. Hohlfeld R, Wekerle H. The immunopathogenesis of myasthenia gravis. In: Engel AG. Myasthenia gravis and myasthenic syndromes. Oxford: University Press 1999: 87-110.

30. Spalek P, Smat V, Benko J, Vejvalka J. Thymectomy in juvenile myasthenia gravis. Prague: VIth International Symposium of Child Neurology 1985: 77.

31. Piťha J, Matějková E. Asociace HLA antigenu s myasthenia gravis u české populace. Čes Slov Neurol Neurochir 1998; 61/94: 7-12.

32. Vincent A, Leite MI. Neuromuscular junction autoimmune disease: muscle specific kinase antibodies and treatments for myasthenia gravis. Curr Opin Neurol 2005; 18: 519-525.

33. Selcen D, Fukuta T, Shen XM, Engel AG. Are the MuSK antibodies the primary cause of myasthenic symptoms ? Neurology 2004; 62: 1945-1950.

34. Deymeer F, Gungor-Tuncer O, Yilmaz V, Parman P, Serdaroglu P, Ozdemir A et al. Clinical comparison of anti-MuSK – vs – AchR – positive and seronegative myasthenia. Neurology 2007; 68: 609-611.

35. Wolfe GI, Trivedi JR, Oh SJ. Clinical review of muscle-specific tyrosine kinase-antibody positive myasthenia gravis. J Clin Neuromusc Dis 2007; 8: 217-224.

36. Vincent A, Mc Conville J, Farrugia ME, Newsom-Davis J. Seronegative myasthenia gravis. Sem Neurol 2004; 24: 125-133.

37. Hayashi A, Shiono H, Ohta M, Ohta K, Okumura M, Sawa Y. Heterogeneity of immunopathological features of AChR/MuSK autoantibody-negative myasthenia gravis. J Neuroimmunol 2007; 189: 163-168.

38. Spalek P, Hancinova V, Schnorrer M, Vincent A. Thymomas, myasthenia gravis, associated autoimmune diseases and antibodies against antogens at neuromuscular junction. Eur J Neurol 2006; 13 (Suppl.): 255.

39. Špalek P. Tymómy a paraneoplastická autoimunita. Čes Slov Neurol Neurochir 2002; 65/98: 367-373.

40. Chen XJ, Qiao J, Xiao BG, Lu CZ. The significance of titin antibodies in myasthenia gravis. Correlation with thymoma and severity of myasthenia gravis. J Neurol 2004; 251: 1006-1012.

41. Agius MA, Richman DP, Fairclough RH, Aarli J, Gilhus NE, Romi F. Three forms of immune myasthenia. Ann N Y Acad Sci 2003; 998: 454-456.

42. Osserman KE, Genkins G. Studies in myasthenia gravis: review of twenty year experience in over 1200 patients. Mount Sinai J Med, 1971; 38: 497-537.

43. Beekman R, Kuks JBM, Oosterhuis HJGH. Myasthenia gravis: diagnosis and follow-up of 100 consecutive patients. J Neurol Sci 1997; 244: 112-118.

44. Somnier FE, Keiding N, Paulson OB. Epidemiology of myasthenia gravis in Denmark. A longitudinal and comprehensive population survey. Arch Neurol 1991; 48: 733-739.

45. Phillips LH, Torner JC, Anderson MS, Cox GM. The epidemiology of myasthenia gravis in central and western Virginia. Neurology 1992; 42: 1888-1893.

46. Phillips LH, Torner JC. Epidemiologic evidence for a changing natural history of myasthenia gravis. Neurology 1996; 47: 1233-1238.

47. Vincent A, Palace J, Hilton-Jones D. Myasthenia gravis. Lancet 2001; 357: 2122-2128.

48. Špalek P. Epidemiology of myasthenia gravis in Slovak Republic – a 25 years longitudinal study (1978-2002). Lek Obzor 2003; 52 (Supl.): 2.

49. Niks EH, Kuks JBM, Verschuuren JJ. Epidemiology of myasthenia gravis with anti-muscle specific kinase antibodies in the Netherlands. J Neurol Neurosurg Psychiat 2007; 78: 417-418.

50. Oosterhuis HJGH. The natural course of myasthenia gravis: a long-term follow-up study. J Neurol Neurosurg Psychiat 1989; 52: 1121-1127.

51. Grob D. Natural history of myasthenia gravis. In: Engel AG. Myasthenia gravis and myasthenic disorders. Oxford: University Press 1999: 131-145.

52. Piťha J, Ambler Z. Myasthenia gravis. In: Neurologie 2003: Triton 2003: 188-202.

53. Schumm F. Myasthenia gravis – klinische Aspekte. Akt Neurol 1998; 25(Suppl. 2): 22-27.

54. Szobor A. Myasthenia gravis. Budapest: Akadémiai Kiadó 1990.

55. Simpson JA. Myasthenia gravis and myasthenic syndromes. In: Walton J. Disorders of voluntary muscles. Edinburgh: Churchill Livingstone 1981:585-624.

56. Gangadhar DV, Johnson LN, Borchert M. Isolated weakness of the orbicularis oculi muscle from myasthenia gravis. Neuro-ophtalmology 1989; 9: 327-329.

57. Kaminski HJ, Spiegel P, Ruff RL. Why are eye muscles frequently involved in

in myasthenia gravis? Neurology 1990; 40: 1663-1669.

58. Dziewas R, Warnecke T, Ritter M, Dittrich R, Schilling M, Schabitz WR et al. Fatigable swallowing in myasthenia gravis – proposal of a standardized test and report of a case. J Clin Neuromusc Dis 2006; 8: 12-15.

59. Llabrés M, Molina-Martinez FJ, Miralles F. Dysphagia as the sole manifestation of myasthenia gravis. J Neurol Neurosurg Psychiat 2005; 76: 1297-1300.

60. Nicolle MW. Wrist and finger drop in myasthenia gravis. J Clin Neuromusc Dis 2006; 8: 65-69.

61. Špalek P. Antibiotiká a neuromuskulárna transmisia. Prakt Lék 1982; 62: 130-132.

62. Ambler Z. Inhibiční vpliv léku na nervosvalový prenos. Farmakoter Zpravy 1989; 35: 49-53.

63. Mičeková D, Ondrašík M, Špalek P, Švec V. Myasthenia gravis pri liečbe reumatoidnej artritídy D-penicilamínom. Prakt Lék 1986; 66: 649-650.

64. Kuncl RW, Pestronk A, Drachman DB, Rechthand E. The pathophysiology of penicilamine-induced myasthenia gravis. Ann Neurol 1986; 20: 740-744.

65. Drosos AA, Christou L, Galanapoulou V, Tziofa AG, Tsiakou EK. D-penicilamine induced myasthenia gravis: clinical, serological and genetic findings. Clin Exp Rheumatol 1993; 11:387-391.

66. Leker RR, Karni A, Abramsky O. Exacerbation of myasthenia gravis during the menstrual period. J Neurol Sci 1988; 156: 107-111.

67. Špalek P. Myasthenia gravis, tehotnosť a tranzitórna neonatálna myasténia. Prakt Gynekol 1996; 3: 129-132.

68. Hoff JM, Daltveit AK, Gilhus NE. Myasthenia gravis in pregnancy and birth: identifying risk factors, optimising care. Eur J Neurol 2007; 14: 38-43.

69. Spalek P, Soskova M, Oros M. Myasthenia gravis, pregnancy and transient neonatal myasthenia. Neuromusc Dis 2002; 8: 735.

70. Brenner T, Abramsky O, Lisak RP. Influence of alpha-fetoprotein in vitro and in vivo immune responses to acetylcholine receptor. Ann N Y Acad Sci 1981; 377: 208-221.

71. Kalischewski P, Berrouschot J, Baumann I, Wagner A, Schneider D. Krisen bei Myasthenia Gravis, Management und Therapie auf der Neurologischen Intensivsstation. Akt Neurol 1998; 25 (Suppl 2): 62-63.

72. Hughes RAC, McLuckie A. Acute neuromuscular paralysis. In: Hughes RAC. Neurological Emergencies. London: BMJ Books: 332-358.

73. Drábková J. Myasthenia gravis z pohledu intenzívní medicíny. In: Schutzner J, Šmat V. Myasthenia gravis. Komplexní pojetí a chirurgická léčba. Praha: Galén 2005: 93-112.

74. Bedlack RS, Sanders DB. On the concept of myasthenic crisis. J Clin Neuromusc Dis 2002; 4: 40-42.

75. Schroer C, Bucka C, Sokolowski P, Kohler W. Myasthenia gravis – Klassifikationen und Scores. Akt Neurol 1998; 25 (Suppl. 2): 30-32.

76. Oosterhuis HJGH, Limburg PC, Hummel-Tappel E, The TH. Anti-acetylcholine receptor antibodies in myasthenia gravis: clinical and serological follow-up of individual patients. J Neurol Sci 1983; 58: 371-385.

77. Besinger UA, Toyka KV, Heininger K. Long-term correlation of clinical course and acetylcholine receptor antibody in patients with myasthenia gravis. Ann N Y Acad Sci 1981: 371-379.

78. Jaretzki A, Barohn RJ, Ernstoff RM. Myasthenia gravis. Recomendations for clinical research standards. Neurology 2000; 55: 16-23.

79. Schutzner J, Tvrdoň J. Chrurgická léčba thymomu. In: Schutzner J, Šmat V. Myasthenia gravis. Komplexní pojetí a chirugická léčba. Praha: Galén 2005: 63-72.

80. Špalek P, Schnorrer M. Tymómy: nové poznatky a ich nová WHO klasifikácia.

Lek Obzor 2002; 51: 248-250.

81. Koc F, Yerdelen D, Sarica Y. Myasthenia gravis and invasive thymoma with multiple intracranial metastases. J Clin Neuromusc Dis 2003; 4: 171-173.

82. Spalek P, Orolin D, Lisy L. Immunosuppressive drug treatment in overlap myasthenic syndrome: combined myasthenia gravis and Lambert-Eaton myasthenic syndrome. In: Bartko D, Gersterbrand F, Turcani P. Neurology in Europe I. London: John Libbey and Co Ltd 1989: 603-607.

83. Spalek P, Brozman B, Lisy L, Vincent A. Lambert-Eaton myasthenic syndrome – recent developments, diagnostic methods and case report of a patient with concomitant myasthenia gravis. Čes Slov Neurol Neurochir 1999; 62/95: 163-166.

84. Špalek P, Schnorrer M, Cibulčík F. Kombinovaný výskyt akútnej myasténie gravis a akútnej polymyozitídy u troch pacientov, u dvoch v asociácii s tymómom. Rozhl Chir 2000; 79: 468-470.

85. Spalek P, Cibulcik F, Vincent A. Myasthenia gravis and associated neurologic autoimmune disorders. Neuromusc Dis 2004; 14: 618.

86. Sneddon J. Myasthenia gravis – a difficult diagnosis. Brit J Psychiat 1980; 136: 92-93.

87. Sorensen TT, Hol EB: Myasthenia gravis in county of Viborg, Denmark. Eur Neurol 1989; 29:177-179.

88. Gorelick PB, Rosenberh M, Pagano RJ. Enhanced ptosis in myasthenia gravis. Arch Neurol 1981; 38: 531.

89. Ambler Z, Stalberg E. EMG diagnostika myasthenie gravis. Čs Neurol Neurochir 1986; 49/82: 60-65.

90. Ambler Z, Stalberg E. Myasthenický syndróm a jeho EMG diagnostika. Čs Neurol. Neurochir 1986; 49/82: 66-69.

91. Stalberg E, Sanders DB. Electrophysiological tests of neuromuscular transmission. In: Clinical neurophysiology. London: Butterworths 1981: 88-116.

92. Ambler Z. Aktivační testy při diagnostice myasthenie gravis repetititivní stimulací. Čs Neurol Neurochir 1990; 53/86: 78-82.

93. Špalek P, Hupka Š. Diagnostický význam stapediovej reflexometrie pri myasthenia gravis. Čas Lék čes 1982; 45: 1388-1390.

94. Seybold ME. Treatment of myasthenia gravis. In: Engel AG. Myasthenia gravis and myasthenic syndromes. Oxford: Univesity Press 1999:167-201.

95. Wolfe GI, Gross B. Treatment review and update for myasthenia gravis. J Clin Neuromusc Dis 2004; 6: 54-98.

96. Janzen RWC. Basistherapie der Myasthenie – Azethylcholinesterasehemmer (AchE-Hemmer). Akt Neurol 1998; 25 (Suppl. 2): 42-45.

97. Piťha J, Šimková L, Nováková I. Konzervatívní terapie myasthenia gravis. In: Schutzner J, Šmat V. Myasthenia gravis. Komplexní pojetí a chirugická léčba. Praha: Galén 2005: 79-91.

98. Bedlack RS, Sanders DB. Steroid treatment for myasthenia gravis. Steroids have an important role. Muscle Nerve 2002; 25: 117-121.vv

99. Seybold ME, Drachman DB. Gradually increasing doses of prednisone in myasthenia gravis: reducing the hazards of treatment. N Engl J Med 1974; 290: 81-64.

100. Johns TR. Long-term corticosteroid treatment of myasthenia gravis. Ann NY Acad Sci 1987: 505: 568-583.

101. Spalek P, Lisy L. Long-term immunosuppressive therapy in 134 myasthenia gravis patients. J Neurol Sci 1990; 90 (Suppl): 415-416.

102. Kuks JBM, Djojoatmodjo S, Oosterhuis HJGH. Azathioprine in myasthenia gravis: observation in 41 patients and review of literature. Neuromusc Disord 1991; 1:423-431.

103. Myasthenia Gravis Clinical Study Group. A randomized clinical trial comparing prednison and azathioprine in myasthenia gravis: results of the second interim analysis. J Neurol Neurosurg Psychiat 1993; 56: 1157-1163.

104. 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: 1778-1883.

105. Spalek P. Register of myasthenia gravis and myasthenic syndromes in Slovak Republic. Oxford: Euro-Myasthenia III 1991: 52.

106. Drachman DB, Jones RJ, Brodsky RA. Treatment of refractory myasthenia: „rebooting“ with high-dose cyclophosphamide. Ann Neurol 2003; 53: 29-34.

107. Wakata N, Saito T, Tanaka S. Tacrolimus hydrate (FK 506): therapeutic effects and selection of responders in the treatment of myasthenia gravis. Clin Neurol Neurosurg 2003; 106: 5-8.

108. Piťha J. První zkušenosti s terapií cyklosporinem A u myasthenia gravis. Čes Slov Neurol Neurochir 1994; 57/90: 237-241.

109. Hauser RA, Malek AR, Rosen R. Succesful treatment of a patient with severe refractory myasthenia gravis using mycophenolate mofetil. Neurology 1998; 51: 912-913.

110. Meriggioli MN, Rowin J, Richamn JG. Mycophenolate mofetil for myasthenia gravis: a double blind, placebo controlled pilot study. Ann NY Acad Sci 2003; 998: 494-499.

111. Mee J, Paine M, Byrne E. Immunotherapy of ocular myasthenia gravis reduces conversion to generalized myasthenia gravis. J Neuroophtalmol 2003; 23: 251-255.

112. Šmat V, Vejvalka J. Význam thymektomie v léčbě myasthenia gravis. Čs. Neurol Neurochir 1970: 33/66: 246-251.

113. Špalek P, Orolin D, Siman J. Tymektómia v liečbe myasténie gravis. Lék Obzor 1989; 38: 309-312.

114. Schnorrer M, Spalek P, Belacek J, Carsky S. Thymom und Myasthenia gravis. Viszeralchirurgie 1998; 33: 171-174.

115. Schnorrer M, Hraška V, Špalek P, Čársky S. Stanovenie významu prognostických faktorov pri chirurgickej liečbe myasténie gravis. Rozhl Chir 1999; 78: 223-227.

116. Spalek P, Schnorrer M, Sitarova K. Thymectomy in 347 myasthenia gravis patients (1990-2006). Eur J Neurol 2007; 14 (Suppl 1): 270.

117. Schutzner J, Šmat V. Thymus a chirugická léčba myasthenia gravis. In: Schutzner J, Šmat V. Myasthenia gravis. Komplexní pojetí a chirurgická léčba. Praha: Galén 2005: 31-61.

118. Lanska DJ. Indication for thymectomy in myasthenia gravis. Neurology 1990; 40: 1828-1829.

119. Gronseth GS, Barohn RJ. Thymectomy for nonthymomatous autoimmune myasthenia gravis (an evidence-based review). Neurology 2000; 55: 7-15.

120. Špalek P, Schnorrer M, Sosková M, Sitárová K. Myasthenia gravis – analýza faktorov ovplyvňujúcich terapeutickú efektívnosť tymektómie. Čes Slov Neurol Neurochir 2007; 70/103 (Suppl): 26.

121. Cavanagh NPC. The role of thymectomy in childhood myasthenia. Develop Med Child Neurol 1980; 22: 668-674.

122. Spalek P, Orolin D, Smat V. Myasthenia gravis and myasthenic syndromes in children J Autoim 1989; 2: 947.

123. Jaretzki A III. Thymectomy for myasthenia gravis: analysis of controversies regarding technique and results. Neurology 1997; 48 (Suppl 5): 52-63.

124. Spalek P, Hlavacikova M, Babincova A. Plasmapheresis in therapy of immunopathological neurological diseases. Piestany: Proceedings of International Congress on Haematology 2000: 55-56.

125. Gajdos P, Chevret S, Clair B, Tranchant C, Chastang C. Clinical trial of plasma exchange and high-dose intravenous immunoglobulin in myasthenia gravis: Myasthenia Gravis Clinical Study Group. Ann Neurol 1997; 41: 789-796.

126. Yeh JH, Chen WH, Chiu HCh, Bai ChH. MuSK antibody clearence during serial sessions of plasmapheresis for myasthenia gravis. J Neurol Sci 2007; 263: 191-193.

127. Pták J. Imunoadsorbce – nová možnost léčby autoimunitních onemocnění. Prakt Lék 2000; 82: 336-339.

128. Bednařík J, Voháňka S, Kadaňka Z. Léčba autoimunitních nervosvalových onemocnění intravenóznym lidským imunoglobulinem – přehled problematiky. Čes Slov Neurol Neurochir 1999; 62/95: 67-74.

129. Evoli A, Palmisani MT, Bartoccioni E, Padua L, Tonali P. High-dose intravenous immunoglobulin in myasthenia gravis. Ital J Neurol Sci 1993; 14: 233-237.

130. Newsom-Davis J. Myasthenia gravis and the Lambert Eaton myasthenic syndrome. In: Said G. Treatment of neurological disorders with intravenous immunoglobulins. London: Martin Dunitz 2000: 93-101.

131. Hain B, Jordan K, Deschauer M, Zierz S. Successful treatment of MuSK antibody-positive myasthenia gravis with rituximab- Muscle Nerve 2006; 33: 575-580.

132. Rowin J, Meriggioli MN, Tuzun E, Leurgans S, Christadoss P. Etanercept treatment in corticosteroid-dependent myasthenia gravis. Neurology 2004; 63: 2390-2392.

133. Nizri E, Hamra-Amitay Y, Sicsic C, Lavon I, Brenner T. Anti-inflammatory properties of cholinergic up-regulation: A new role for acetylcholinesterase inhibitors. Neuropharmacology 2006; 50: 540-547.