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Myasthenia Gravis in the Elderly: Differential Diagnosis and Management

  • Neurology of Aging (K Marder, Section Editor)
  • Published:
Current Geriatrics Reports Aims and scope Submit manuscript

Abstract

Late-life disorders presenting with weakness often have a delay in diagnosis leading to decreased quality of life and impairment of mobility. Myasthenia gravis is an immune disorder affecting the neuromuscular junction resulting in varying levels of weakness in the orbital, bulbar, and limb muscles. The evaluation of weakness in the elderly should be geared toward treatable and reversible causes such as myasthenia gravis. The major treatment options include symptomatic, immunosuppressive, and immunomodulating therapies.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Sanders DB, Guptill JT. Myasthenia gravis and Lambert-Eaton myasthenic syndrome. Continuum (Minneap Minn). 2014;20(5):1413–25.

    Google Scholar 

  2. Alkhawajah NM, Oger J. Treatment of myasthenia gravis in the aged. Drugs Aging. 2015;32(9):689–97. A good review of myasthenia gravis treatment and special considerations in the other population.

    Article  CAS  PubMed  Google Scholar 

  3. Casetta I, Groppo E, De Gennaro R, Cesnik E, Piccolo L, Volpato S, et al. Myasthenia gravis: a changing pattern of incidence. J Neurol. 2010;257(12):2015–9.

    Article  CAS  PubMed  Google Scholar 

  4. Avidan N, Le Panse R, Berrih-Aknin S, Miller A. Genetic basis of myasthenia gravis—a comprehensive review. J Autoimmun. 2014;52:146–53.

    Article  CAS  PubMed  Google Scholar 

  5. Nagia L, Lemos J, Abusamra K, Cornblath WT, Eggenberger ER. Prognosis of ocular myasthenia gravis. Ophthalmology. 2015;122(7):1517–21.

    Article  PubMed  Google Scholar 

  6. Padua L, Caliandro P, Di Iasi G, Pazzaglia C, Ciaraffa F, Evoli A. Reliability of SFEMG in diagnosing myasthenia gravis: sensitivity and specificity calculated on 100 prospective cases. Clin Neurophysiol. 2014;125(6):1270–3. Looks at the utility of SFEMG in diagnosing myasthenia gravis with calculation of positive and negative predictive values.

    Article  CAS  PubMed  Google Scholar 

  7. Hellmann MA, Mosberg-Galili R, Steiner I. Myasthenia gravis in the elderly. J Neurol Sci. 2013;325(1-2):1–5.

    Article  PubMed  Google Scholar 

  8. Sanders DB, Burns TM, Cutter GR, et al. Does change in acetylcholine receptor antibody level correlate with clinical change in myasthenia gravis? Muscle Nerve. 2014;49(4):483–6.

    Article  CAS  PubMed  Google Scholar 

  9. Zhang B, Tzartos JS, Belimezi M, et al. Autoantibodies to lipoprotein-related protein 4 in patients with double-seronegative myasthenia gravis. Arch Neurol. 2012;69(4):445.

    Article  PubMed  Google Scholar 

  10. Zouvelou V, Zisimopoulou P, Rentzos M, et al. Double seronegative myasthenia gravis with anti-LRP 4 antibodies. Neuromuscul Disord. 2013;23(7):568–70.

    Article  PubMed  Google Scholar 

  11. Tsivgoulis G, Dervenoulas G, Kokotis P, et al. Double seronegative myasthenia gravis with low density lipoprotein-4 (LRP4) antibodies presenting with isolated ocular symptoms. J Neurol Sci. 2014;346(1-2):328–30.

    Article  CAS  PubMed  Google Scholar 

  12. Jiang L, Wu W, Guan W, Wu Z, Nie Y. Overlooked myasthenia gravis in an elderly adult. J Am Geriatr Soc. 2013;61(5):840–1.

    Article  PubMed  Google Scholar 

  13. Mongiovi PC, Elsheikh B, Lawson VH, Kissel JT, Arnold WD. Neuromuscular junction disorders mimicking myopathy. Muscle Nerve. 2014;50(5):854–6.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Imai T, Suzuki S, Tsuda E, Nagane Y, Murai H, Masuda M, et al. Oral corticosteroid therapy and present disease status in myasthenia gravis. Muscle Nerve. 2014;51(5):692–6. Looks at history of steroid use and compares to current disease status to determine factors that are predictive of the current disease status.

    Article  Google Scholar 

  15. Ebadi H, Barth D, Bril V. Safety of plasma exchange therapy in patients with myasthenia gravis. Muscle Nerve. 2013;47(4):510–4.

    Article  CAS  PubMed  Google Scholar 

  16. Barth D, Nabavi Nouri M, Ng E, Nwe P, Bril V. Comparison of IVIg and PLEX in patients with myasthenia gravis. Neurology. 2011;76:2017–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Sanders DB, Hart IK, Mantegazza R, et al. An international, phase III, randomized trial of mycophenolate mofetil in myasthenia gravis. Neurology. 2008;71:400–6.

    Article  CAS  PubMed  Google Scholar 

  18. Muscle Study Group. A trial of mycophenolate mofetil with prednisone as initial immunotherapy in myasthenia gravis. Neurology. 2008;71(6):394–9.

    Article  Google Scholar 

  19. Hehir MK, Burns TM, Alpers J, Conaway MR, Sawa M, Sanders DB. Mycophenolate mofetil in AChR-antibody-positive myasthenia gravis: outcomes in 102 patients. Muscle Nerve. 2010;41(5):593–8.

    Article  CAS  PubMed  Google Scholar 

  20. Hobson-Webb LD, Hehir M, Crum B, Visser A, Sanders D, Burns TM. Can mycophenolate mofetil be tapered safely in myasthenia gravis? A retrospective, multicenter analysis. Muscle Nerve. 2015;52:211–5. Looks at tapering of mycophenalate and that it can be done safely and usually needs to be done slowly.

    Article  PubMed  Google Scholar 

  21. Heckmann JM, Rawoot A, Bateman K, Renison R, Badri M. A single-blinded trial of methotrexate versus azathioprine as steroid-sparing agents in generalized myasthenia gravis. BMC Neurol. 2011;11(1):97.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Pasnoor M, He J, Herbelin L, Dimachkie M, Barohn RJ, Muscle Study Group. Phase II trial of methotrexate in myasthenia gravis. Ann N Y Acad Sci. 2012;1275(1):23–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Barohn R. Efficacy of methotrexate in myasthenia gravis—study results—ClinicalTrials. ClincalTrials.gov.https://clinicaltrials.gov/ct2/show/results/NCT00814138?term= myasthenia+gravis&rank=4&sect=X56#base. Published 2015. Clinical trial results of a trial that showed no difference between methotrexate and placebo in MG patients.

  24. Nakamura S, Kaneko S, Shinde A, et al. Prednisolone-sparing effect of cyclosporin A therapy for very elderly patients with myasthenia gravis. Neuromuscul Disord. 2013;23(2):176–9. Shows that cyclosporin can be used safely and effectively in elderly patients with MG.

    Article  PubMed  Google Scholar 

  25. Yoshikawa H, Kiuchi T, Saida T, Takamori M. Randomised, double-blind, placebo-controlled study of tacrolimus in myasthenia gravis. J Neurol Neurosurg Psychiatry. 2011;82(9):970–7.

    Article  PubMed  Google Scholar 

  26. Collongues N, Casez O, Lacour A, et al. Rituximab in refractory and non-refractory myasthenia: a retrospective multicenter study. Muscle Nerve. 2012;46(5):687–91.

    Article  CAS  PubMed  Google Scholar 

  27. Nowak RJ, Yale University. Phase II trial of rituximab in myasthenia gravis—full text view—ClinicalTrials. ClincalTrials.gov. https://clinicaltrials.gov/ct2/show/study/NCT02110706?term=myasthenia+gravis&rank=15. Published 2015. Accessed January 21, 2016. Important ongoing trial of use of rituximab in MG patients and positive results may have significant effects on how future MG patients are treated.

  28. Howard JF, Barohn RJ, Cutter GR, et al. A randomized, double-blind, placebo-controlled phase II study of eculizumab in patients with refractory generalized myasthenia gravis. Muscle Nerve. 2013;48(1):76–84.

    Article  CAS  PubMed  Google Scholar 

  29. Jurado J, Javidfar J, Newmark A, et al. Minimally invasive thymectomy and open thymectomy: outcome analysis of 263 patients. Ann Thorac Surg. 2012;94(3):974–82.

    Article  PubMed  Google Scholar 

  30. Mineo TC, Ambrogi V. Outcomes after thymectomy in class I myasthenia gravis. J Thorac Cardiovasc Surg. 2013;145(5):1319–24.

    Article  PubMed  Google Scholar 

  31. Lo C-M, Lu H-I, Hsieh M-J, Lee S-S, Chang J-P. Thymectomy for myasthenia gravis: video-assisted versus transsternal. J Formos Med Assoc. 2014;113(10):722–6.

    Article  PubMed  Google Scholar 

  32. Gamez J. Intravenous immunoglobulin for preparing myasthenia gravis patients for thymectomy and other surgical procedures preventing myasthenic crisis. Clin Exp Immunol. 2014;178(Suppl):134–5. An ongoing study that is looking at IVIG as pre-treatment to prevent myasthenic crisis associated with thymectomy, and, if positive, may change current practice from recommended to required pre-treatment.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Askmark H, Haggård L, Nygren I, Punga AR. Vitamin D deficiency in patients with myasthenia gravis and improvement of fatigue after supplementation of vitamin D3: a pilot study. Eur J Neurol. 2012;19(12):1554–60.

    Article  CAS  PubMed  Google Scholar 

  34. Khadilkar SV, Chaudhari CR, Patil TR, Desai ND, Jagiasi KA, Bhutada AG. Once myasthenic, always myasthenic? Observations on the behavior and prognosis of myasthenia gravis in a cohort of 100 patients. Neurol India. 2014;62(5):492–7. Looks at prognosis of myasthenic patients and percentages of patients who become minimally symptomatic on and off treatment.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neurology, Hospital for Special Surgery, 525 East 71st Street, Belaire 5th floor, New York, NY, 10021, USA

    Erin Manning & Jonathan M. Goldstein

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  1. Erin Manning
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  2. Jonathan M. Goldstein
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Correspondence to Erin Manning.

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Jonathan Goldstein and Erin Manning declare that they have no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Neurology of Aging

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Manning, E., Goldstein, J.M. Myasthenia Gravis in the Elderly: Differential Diagnosis and Management. Curr Geri Rep 5, 78–84 (2016). https://doi.org/10.1007/s13670-016-0170-0

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  • DOI: https://doi.org/10.1007/s13670-016-0170-0

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