Myasthenia gravis (MG) is a long-term neuromuscular junction disease that leads to varying degrees of skeletal muscle weakness. The most commonly affected muscles are those of the eyes, face, and swallowing. It can result in double vision, drooping eyelids, and difficulties in talking and walking. Onset can be sudden. A small percentage of patients can have an enlarged thymus or rarely a thymoma.
Myasthenia gravis is an autoimmune disease of the neuromuscular junction which results from antibodies that block or destroy nicotinic acetylcholine receptors (AChR) at the junction between the nerve and muscle. This prevents nerve impulses from triggering muscle contractions. Most cases are due to immunoglobulin G1 (IgG1) and IgG3 antibodies that attack AChR in the postsynaptic membrane, causing complement-mediated damage and muscle weakness. Rarely, an inherited genetic defect in the neuromuscular junction results in a similar condition known as congenital myasthenia. Babies of mothers with myasthenia may have symptoms during their first few months of life, known as neonatal myasthenia or more specifically transient neonatal myasthenia gravis. Diagnosis can be supported by blood tests for specific antibodies, the edrophonium test, electromyography (EMG), or a nerve conduction study.
Mild forms of myasthenia gravis may be treated with medications known as acetylcholinesterase inhibitors, such as neostigmine and pyridostigmine. But these drugs only provide symptomatic relief. Therefore almost all patients will in addition require immunosuppressants, such as prednisone, mycophenolate or azathioprine, as acetylcholinesterase inhibitors alone are insufficient. The surgical removal of the thymus may improve symptoms in certain cases. Plasmapheresis and high-dose intravenous immunoglobulin may be used when oral medications are insufficient to treat severe symptoms, including during sudden flares of the condition.
On rare occasions the respiratory muscles can become significantly weak, subsequent mechanical ventilation may then be required. Once intubated, acetylcholinesterase inhibitors may be temporarily withheld to reduce airway secretions.
Myasthenia gravis affects 50 to 200 people per million. It is newly diagnosed in 3 to 30 people per million each year. Increased awareness has made diagnosis more common. Myasthenia gravis most commonly occurs in women under the age of 40 and in men over the age of 60. It is uncommon in children.
With treatment, most have fulfilling lives and have a normal life expectancy. The word is from the Greek mys, "muscle" and asthenia "weakness", and the Latin gravis, "serious".
Signs and symptoms The initial, main symptom in myasthenia gravis is painless weakness of specific muscles, not fatigue. The muscle weakness becomes progressively worse (fatigue) during periods of physical activity and improves after periods of rest. Typically, the weakness and fatigue are worse toward the end of the day. Myasthenia gravis generally starts with ocular (eye) weakness; it might then progress to a more severe generalized form, characterized by weakness in the extremities or in muscles that govern basic life functions.
Eyes In about two-thirds of people, the initial symptom of myasthenia gravis is related to the muscles around the eye. Eyelid drooping (ptosis may occur due to weakness of m. levator palpebrae superioris) and double vision (diplopia, due to weakness of the extraocular muscles). Eye symptoms tend to get worse when watching television, reading, or driving, particularly in bright conditions. Consequently, some affected individuals choose to wear sunglasses. The term "ocular myasthenia gravis" describes a subtype of myasthenia gravis where muscle weakness is confined to the eyes, i.e., extraocular muscles, m. levator palpebrae superioris, and m. orbicularis oculi. This subtype may evolve into generalized myasthenia gravis, usually after a few years. If an individual with ocular myasthenia gravis does not generalize for three or more years after the onset of symptoms, then generalized myasthenia gravis is unlikely to occur.
Eating The weakness of the muscles involved in swallowing may lead to swallowing difficulty (dysphagia). Typically, this means that some food may be left in the mouth after an attempt to swallow, or food and liquids may regurgitate into the nose rather than go down the throat (velopharyngeal insufficiency). Weakness of the muscles that move the jaw (muscles of mastication) may cause difficulty chewing. In individuals with myasthenia gravis, chewing tends to become more tiring when chewing tough, fibrous foods. Difficulty in swallowing, chewing, and speaking is the first symptom in about one-sixth of individuals.
Speaking Weakness of the muscles involved in speaking may lead to dysarthria and hypophonia. Speech may be slow and slurred, or have a nasal quality. In some cases, a singing hobby or profession must be abandoned.
Head and neck Due to weakness of the muscles of facial expression and muscles of mastication, facial weakness may manifest as the inability to hold the mouth closed (the "hanging jaw sign") and as a snarling expression when attempting to smile. With drooping eyelids, facial weakness may make the individual appear sleepy or sad. Difficulty in holding the head upright may occur.
Other The muscles that control breathing and limb movements can also be affected; rarely do these present as the first symptoms of myasthenia gravis, but develop over months to years. In a myasthenic crisis, a paralysis of the respiratory muscles occurs, necessitating assisted ventilation to sustain life. Crises may be triggered by various biological stressors such as infection, fever, an adverse reaction to medication, or emotional stress.
Causes Medications that cause or worsen myasthenia gravis Antibiotics: In the macrolide family of antibiotics, azithromycin, telithromycin (which is no longer available in the U.S. market), and erythromycin are reported to exacerbate myasthenia gravis. In the fluoroquinolone antibiotic family, ciprofloxacin, norfloxacin, ofloxacin, and moxifloxacin are reported to exacerbate myasthenia gravis. And, In the aminoglycoside family of antibiotics, gentamicin, streptomycin, and neomycin are reported to exacerbate myasthenia gravis. The aminoglycoside tobramycin has not been reported to exacerbate myasthenia gravis and may be used in people that require aminoglycoside treatment. Because of the rarity or absent reports on their exacerbation of myasthenia gravis, the following antibiotics are considered safe to use in people with myasthenia gravis: the cephalosporin class of drugs, sulfa drugs, the tetracycline group of drugs, clindamycin, polymyxin B, and nitrofurantoin. Immune checkpoint inhibitors: Immune checkpoint inhibitors promote certain types of autoimmune responses by blocking checkpoint pathways that inhibit these responses. They are used to treat cancers that promote their own growth and spread by stimulating checkpoint pathways. These checkpoint inhibitors include pembrolizumab, nivolumab, ipilimumab, avelumab, atezolizumab, and durvalumab. From a total 5,898 people who received these drugs, 52 developed new onset myasthenia gravis and 11 had a flare of their preexisting myasthenia gravis. The symptoms of myasthenia gravis developed within 6 days to 16 weeks (median time 4 weeks). Their medicine-induced myasthenia gravis symptoms were often severe with 29 people developing respiratory failure that required mechanical ventilation. Other studies have reported that these checkpoint inhibitors cause respiratory failure in 45% and death in 25–40% of people with myasthenia gravis. Statins: Statins are drugs that lower blood cholesterol levels in order to reduce the risk of developing a cardiovascular disease due to atherosclerosis. In a 2019 review of 169 people who were reported to develop myasthenia gravis or had worsened myasthenia gravis symptoms while taking a statin, 138 had developed generalized myasthenia gravis, 13 had developed ocular myasthenia gravis, and 18 had worsening of their myasthenia gravis. Following discontinuance of the statin and treatment of their myasthenia gravis, 63 people fully recovered, 27 people were recovering, 19 people had not yet recovered, 5 people recovered but had ongoing symptoms, 1 individual had died, and there was no follow-up data for 54 people. Among these cases, 56% were considered to be serious. A 2024 study evaluated 593 people who had myasthenia gravis and 790,399 people who did not have myasthenia gravis after being treated with a statin. The statin-treatment caused small but statistically significant increases in numbers of exacerbations of myasthenia gravis as well as new onsets of myasthenia gravis in people without the disorder. The development of myasthenia gravis in people without myasthenia gravis appeared to be more likely in people over 60 years of age. Six non-statin cholesterol-lowering drugs, nicotinic acid, cholestyramine, colestipol, colesevelam, alirocumab, and evolocumab, have been used in people without causing or worsening myasthenia gravis. Beta blockers: Beta blockers (i.e., β-blockers) are drugs that block the binding of two stress hormones, epinephrine and norepinephrine, to their target beta receptors. They are used to decrease the heart rate, reduce the force of heart contractions, and relax blood vessels in order to lower blood pressure and reduce the workload on the heart. In one study the odds of an myasthenia gravis exacerbation after taking a beta blocker was increased 2.7-fold compared with people with myasthenia gravis not taking a beta blocker. These exacerbations generally did not occur immediately after their usage and therefore may have reflected other comorbidities in people with myasthenia gravis being treated with beta blockers. In a study of 20 people with myasthenia gravis treated with a beta blocker, 3 who received oral metoprolol, 9 who received intravenous metoprolol, 1 who received oral labetalol, and 9 who received intravenous labetalol, only one (i.e., 5%) of the 20 participants (who received intravenous labetalol) reacted with an exacerbation of myasthenia gravis symptoms. Ia antiarrhythmic agents: A type Ia antiarrhythmic agent (see Vaughan Williams classification), i.e., procainamide, which is used to treat cardiac arrhythmias, has caused respiratory failure in people with myasthenia gravis who, prior to being treated with it, did not have respiratory symptoms. Furthermore, this drug has caused MG-like symptoms in people who have kidney failure but do not have myasthenia gravis. And, procainamide worsened muscle dysfunction in a rat model of human myasthenia gravis. Depolarizing neuromuscular blockers: Depolarizing neuromuscular blockers suppress the neurons' signaling at neuromuscular junctions thereby reducing the affected skeletal muscles contractibility. These blockers are used as muscle relaxants in people undergoing surgery. Succinylcholine is the only depolarizing neuromuscular blocker available in the US market. Succinylcholine's ability to induce or worsen myasthenia gravis is unclear. It has been suggested to cause life-threatening side effects such as rhabdomyolysis, myotonia, and hyperkalemia in people with muscle disease although the role of succinylcholine in causing these side effects also remains unclear.