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November 11, 1983, Vol 250, No. 18 >
ARTICLE | November 11, 1983

Myasthenia Gravis: Title and subTitle BreakA Clinical and Basic Science Review FREE

Marjorie E. Seybold, MD
[+] Author Affiliations

Reprint requests to Neurology Service, Veterans Administration Medical Center, 3350 La Jolla Village Dr, San Diego, CA 92161 (Dr Seybold).


JAMA. 1983;250(18):2516-2521. doi:10.1001/jama.1983.03340180070033
Text Size: A A A
Published online
Article
References

MYASTHENIA gravis (MG) is an autoimmune disorder caused by antibodies directed against the acetylcholine receptor (AChR) of skeletal muscle. Although the prevalence of MG is only about one per 20,000 people in the United States, it is the best studied and best understood of the neuroreceptor disorders. As such, it is likely to serve as the prototype for the understanding of more common organ-specific autoimmune disorders.

Clinical Characteristics  Myasthenia gravis has no racial or geographic predilection. Although it is extremely rare during the first two years of life, MG may occur at almost any age. Females are affected more commonly than males (about 2:1), and this female preponderance is most striking during young adulthood. The disease shows decreasing sexual preference with increasing age and may even show a slight male preponderance in the elderly. Familial cases are uncommon, and no consistent HLA type or genetic inheritance pattern has been identified.

REFERENCES

1 +
Perlo VP, Arnason B, Castleman B:  The thymus gland in elderly patients with myasthenia gravis . Neurology 1975;;25:294-295.
2 +
Lisak RP, Barachi RL:  Treatment and management, in Myasthenia Gravis , vol 11, in Walton JN (ed): Major Problems in Neurology . Philadelphia, WB Saunders Co, 1982;, p 209.
3 +
Osserman KE, Tsairis P, Weiner LB:  Myasthenia gravis and thyroid disease: Clinical and immunologic correlation . Mt Sinai J Med 1967;; 34:469-483.
4 +
Engel AG:  Morphologic and immunopathologic findings in myasthenia gravis and in congenital myasthenic syndromes . J Neurol Neurosurg Psychiatry 1980;;43:577-589.
5 +
Seybold ME, Lindstrom JM:  Myasthenia gravis in infancy . Neurology 1981;;31:476-480.
6 +
Borenstein S, Desmendt JE:  New diagnostic procedures in myasthenia gravis , in Desmedt JE (ed): New Developments in Electromyography and Clinical Neurophysiology . Basel, Switzerland, S Karger AG, 1973;, vol 1, pp 350-375.
7 +
Horowitz SH, Sivak M:  The regional curare test and electrophysiologic diagnosis of myasthenia gravis: Further studies . Muscle Nerve 1978;; 1:432-434.
8 +
Stalberg E:  Clinical electrophysiology in myasthenia gravis . J Neurol Neurosurg Psychiatry 1980;;43:622-633.
9 +
Lindstrom JM, Seybold ME, Lennon VA, et al:  Antibody to acetylcholine receptor in myasthenia gravis: Prevalence, clinical correlates, and diagnostic value . Neurology 1976;;26:1054-1059.
10 +
Lee CY:  Elapid neurotoxins and their mode of action . Clin Toxicol 1970;;3:457-472.
11 +
Bender AN, Ringel SP, Engel WK:  Immunoperoxidase localization of alpha bungarotoxin: A new approach to myasthenia gravis . Ann NY Acad Sci 1976;;274:20-30.
12 +
Mittag TW, Caroscio J:  False-positive immunoassay for acetylcholine-receptor antibody in amyotrophic lateral sclerosis . N Engl J Med 1980;;302:868.
13 +
Chang CC, Lee CY:  Isolation of neurotoxins from the venom of Bungarus multicinctus and their modes of neuromuscular blocking action . Arch Int Pharmacodyn Ther 1963;;144:241-257.
14 +
Seybold ME, Lindstrom JM:  Immunopathology of acetylcholine receptors in myasthenia gravis . Springer Semin Immunopathol 1982;; 5:389-412.
15 +
Fumagalli G, Engel AG, Lindstrom J:  Estimation of degration rate of acetylcholine receptor by external gamma counting in vivo . Mayo Clin Proc 1982;;57:758-764.
16 +
Patrick J, Lindstrom J:  Autoimmune response to acetylcholine receptor . Science 1973;;180:871-872.
17 +
Seybold ME, Lambert EH, Lennon VA, et al:  Experimental autoimmune myasthenia: Clinical, neurophysiologic, and pharmacologic aspects . Ann NY Acad Sci 1976;;274:275-282.
18 +
Lambert EH, Lindstrom JM, Lennon VA:  End-plate potentials in experimental autoimmune myasthenia gravis in rats . Ann NY Acad Sci 1976;;274:300-318.
19 +
Engel AG, Tsujihata M, Lindstrom JM, et al:  The motor endplate in myasthenia gravis and in experimental autoimmune myasthenia gravis: A quantitative ultrastructural study . Ann NY Acad Sci 1976;;274:60-79.
20 +
Engel AG, Sakakibara H, Sahashi K, et al:  Passively transferred experimental autoimmune myasthenia gravis: Sequential and quantitative study of the motor end-plate fine structure and ultrastructural localization of immune complexes (IgG and C3), and of the acetylcholine receptor . Neurology 1979;;29:179-188.
21 +
Lindstrom JM, Lambert EH:  Content of acetylcholine receptor and antibodies bound to receptor in myasthenia gravis, experimental autoimmune myasthenia gravis, and Eaton-Lambert syndrome . Neurology 1978;; 28:130-138.
22 +
Engel AG, Lambert EH, Howard FM Jr:  Immune complexes (IgG and C3) at the motor end-plate in myasthenia gravis: Ultrastructural and light microscopic localization and electrophysiologic correlations . Mayo Clin Proc 1977;;52:267-280.
23 +
Sahashi K, Engel AG, Lambert EH, et al:  Ultrastructural localization of the terminal and lytic ninth complement component (C9) at the motor end-plate in myasthenia gravis . J Neuropathol Exp Neurol 1980;; 39:160-172.
24 +
Lennon VA, Seybold ME, Lindstrom JM, et al:  Role of complement in the pathogenesis of experimental autoimmune myasthenia gravis . J Exp Med 1978;;147:973-983.
25 +
Lennon VA, Lambert EH:  Monoclonal autoantibodies to acetylcholine receptors: Evidence for a dominant idiotype and requirement of complement for pathogenicity . Ann NY Acad Sci 1981;;377:77-95.
26 +
Tzartos SJ, Rand DE, Einarson BL, et al:  Mapping of surface structures of electrophorus acetylcholine receptor using monoclonal antibodies . J Biol Chem 1981;;256:8635-8645.
27 +
Tzartos SJ, Seybold ME, Lindstrom JM:  Specificities of antibodies to acetylcholine receptors in sera from myasthenia gravis patients measured by monoclonal antibodies . Proc Natl Acad Sci USA 1982;;79:188-192.
28 +
Lindstrom JM, Tzartos S, Gullick W:  Structure and function of the acetylcholine receptor molecule studied using monoclonal antibodies . Ann NY Acad Sci 1981;;377:1-19.
29 +
Almond RR, Andrew CG, Appel SH:  Serum globulin in myasthenia gravis: Inhibition of α-bungarotoxin binding to acetylcholine receptors . Science 1974;;186:55-57.
30 +
Lennon VA:  Myasthenia gravis: Diagnosis by assay of serum antibodies . Mayo Clin Proc 1982;;57:723-724.
31 +
Desouki A, Eldefrawi AT, Eldefrawi ME:  A new mechanism revealed for the action of antibodies on acetylcholine receptor function . Exp Neurol 1981;;73:440-450.
32 +
Drachman DB, Adams RN, Stanley EF:  Mechanisms of acetylcholine receptor loss in myasthenia gravis . J Neurol Neurosurg Psychiatry 1980;;43:601-610.
33 +
Christadoss P, Lennon VA, Krco CG, et al:  Genetic control of autoimmunity to acetylcholine receptors: Role of Ia molecules . Ann NY Acad Sci 1981;;377:258-276.
34 +
Waldor MK, Sriram S, McDevitt HO, et al:  In vivo therapy with monoclonal anti I-A antibody suppresses immune responses to acetylcholine receptor . Proc Natl Acad Sci USA 1983;;80:1713-1717.
35 +
DeBaets MH, Einarson B, Lindstrom JM, et al:  Lymphocyte activation in experimental autoimmune myasthenia gravis . J Immunol 1982;; 128:2228-2235.
36 +
Newsom-Davis J, Willcox N, Calder L:  Thymus cells in myasthenia gravis selectively enhance production of anti-acetylcholine-receptor antibody by autologous blood lymphocytes . N Engl J Med 1981;;305:1313-1318.
37 +
Koethe SM, Cook A, McQuillen DP, et al:  Clinical and immunologic correlations in myasthenia gravis: Measurements of Con A stimulated suppressor cell activity . Ann NY Acad Sci 1981;;377:447-453.
38 +
Seybold M, Tsoukas C, Lindstrom J, et al:  Leukoplasmapheresis for myasthenia gravis . Arch Neurol 1982;;39:433-435.
39 +
Harfast B, Huddlestone JR, Braheny S, et al:  Myasthenia gravis: In vitro immunoglobulin production with pokeweed mitogen challenge and B- and T-lymphocyte competence . Clin Immunol Immunopathol 1981;;20:336-345.
40 +
Noguchi SA, Drachman DB, Adams RN, et al:  Lymphocyte responsiveness to acetylcholine receptor in rats with experimental autoimmune myasthenia gravis . Ann Neurol 1980;;8:32-37.
41 +
Gardner JM, Fambrough DM:  Acetylcholine receptor degradation measured by density labeling: Effects of cholinergic ligands and evidence against recycling . Cell 1979;;16:661-674.
42 +
Grob D, Brunner NG, Namba T:  The natural course of myasthenia gravis and effect of therapeutic measures . Ann NY Acad Sci 1981;; 377:652-669.
43 +
Blalock A:  Tumors of the thymic region and myasthenia gravis . Am J Surg 1941;;57:149-150.
44 +
Buckingham JM, Howard FM Jr, Bernatz PE, et al:  The value of thymectomy in myasthenia gravis: A computer-assisted matched study . Ann Surg 1976;;184:453-458.
45 +
Seybold ME, Howard FM Jr, Duane DD, et al:  Thymectomy in juvenile myasthenia gravis . Arch Neurol 1971;;25:385-392.
46 +
Rodriguez M, Gomez MR, Howard FM Jr, et al:  Myasthenia gravis in children: Long-term follow-up . Ann Neurol 1983;;13:504-510.
47 +
Scadding GK, Webster ADB, Ross M, et al:  Humoral immunity before and after thymectomy in myasthenia gravis . Neurology 1979;; 29:502-506.
48 +
Seybold ME, Lindstrom JM:  Patterns of acetylcholine receptor antibody fluctuation in myasthenia gravis . Ann NY Acad Sci 1981;; 377:292-305.
49 +
Seybold ME, Baergen RN, Nave B, et al:  Anti-acetylcholine receptor antibody concentrations after thymectomy in patients with myasthenia gravis . Br Med J 1978;;2:1051-1053.
50 +
Grob D, Namba T:  Corticotropin in generalized myasthenia gravis: Effect of short, intensive courses . JAMA 1966;;198:703-707.
51 +
Osserman KE, Genkins G:  Studies in myasthenia gravis: Short-term massive corticotropin therapy . JAMA 1966;;198:699-702.
52 +
Seybold ME, Drachman DB:  Gradually increasing doses of prednisone in myasthenia gravis: Reducing the hazards of treatment . N Engl J Med 1974;;290:81-84.
53 +
Howard FM Jr, Duane DD, Lambert EH, et al:  Alternate-day prednisone: Preliminary report of a double-blind controlled study . Ann NY Acad Sci 1976;;274:596-607.
54 +
Kornfeld P, Genkins G, Papatestas AE, et al:  Steroid therapy in myasthenia gravis associated with thymoma . Mt Sinai J Med 1978;; 45:106-115.
55 +
Morgutti M, Conti-Tronconi BM, Sghirlanzoni A, et al:  Cellular immune response to acetylcholine receptor in myasthenia gravis: II. Thymectomy and corticosteroids . Neurology 1979;;29:734-738.
56 +
Abramsky O, Tarrab-Hazdai R, Aharonov A, et al:  Immunosuppression of experimental autoimmune myasthenia gravis by hydrocortisone and azathioprine . J Immunol 1976;;117:225-228.
57 +
Sanders DB, Johns TR, Eldefrawi ME, et al:  Experimental autoimmune myasthenia gravis in rats: Modification by thymectomy and prednisolone . Arch Neurol 1977;;34:75-79.
58 +
Mertens HG, Hertel G, Reuther P, et al:  Effect of immunosuppressive drugs (azathioprine) . Ann NY Acad Sci 1981;;377:691-698.
59 +
Lefvert AK, Matell G:  Antibodies against human cholinergic receptor proteins in patients with myasthenia gravis: Studies during immunosuppressive treatment . Acta Med Scand 1977;;201:181-182.
60 +
Reuther P, Fulpius BW, Mertens HG, et al:  Anti-acetylcholine receptor antibody under long-term azathioprine treatment in myasthenia gravis , in Dau PC (ed): Plasmapheresis and the Immunobiology of Myasthenia Gravis . Boston, Houghton Mifflin Co, 1979;, pp 329-342.
61 +
Pestronk A, Drachman DB:  Therapeutic strategies in experimental autoimmune myasthenia gravis . Ann NY Acad Sci 1981;;377:278-290.
62 +
Bergstrom K, Franksson C, Matell G, et al:  The effect of thoracic duct lymph drainage in myasthenia gravis . Eur Neurol 1973;;9:157-167.
63 +
Pinching AJ, Peters DK, Newsom-Davis J:  Remission of myasthenia gravis following plasma exchange . Lancet 1976;;2:1373-1376.
64 +
Dau P:  Response to plasmapheresis and immunosuppressive therapy in sixty myasthenia gravis patients . Ann NY Acad Sci 1981;;377:700-708.
65 +
Hawkey CJ, Newsom-Davis J, Vincent A:  Plasma exchange and immunosuppressive drug treatment in myasthenia gravis: No evidence for synergy . J Neurol Neurosurg Psychiatry 1981;;44:469-475.
66 +
Nielson VK, Paulson OB, Rosenkvist J:  Rapid improvement of myasthenia gravis after plasma exchange . Ann Neurol 1982;;11:160-169.
67 +
Olarte MR, Schoenfeldt RS, Penn AS, et al:  Effect of plasmapheresis in myasthenia gravis 1978-1980 . Ann NY Acad Sci 1981;;377:725-728.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Perlo VP, Arnason B, Castleman B:  The thymus gland in elderly patients with myasthenia gravis . Neurology 1975;;25:294-295.
2 +
Lisak RP, Barachi RL:  Treatment and management, in Myasthenia Gravis , vol 11, in Walton JN (ed): Major Problems in Neurology . Philadelphia, WB Saunders Co, 1982;, p 209.
3 +
Osserman KE, Tsairis P, Weiner LB:  Myasthenia gravis and thyroid disease: Clinical and immunologic correlation . Mt Sinai J Med 1967;; 34:469-483.
4 +
Engel AG:  Morphologic and immunopathologic findings in myasthenia gravis and in congenital myasthenic syndromes . J Neurol Neurosurg Psychiatry 1980;;43:577-589.
5 +
Seybold ME, Lindstrom JM:  Myasthenia gravis in infancy . Neurology 1981;;31:476-480.
6 +
Borenstein S, Desmendt JE:  New diagnostic procedures in myasthenia gravis , in Desmedt JE (ed): New Developments in Electromyography and Clinical Neurophysiology . Basel, Switzerland, S Karger AG, 1973;, vol 1, pp 350-375.
7 +
Horowitz SH, Sivak M:  The regional curare test and electrophysiologic diagnosis of myasthenia gravis: Further studies . Muscle Nerve 1978;; 1:432-434.
8 +
Stalberg E:  Clinical electrophysiology in myasthenia gravis . J Neurol Neurosurg Psychiatry 1980;;43:622-633.
9 +
Lindstrom JM, Seybold ME, Lennon VA, et al:  Antibody to acetylcholine receptor in myasthenia gravis: Prevalence, clinical correlates, and diagnostic value . Neurology 1976;;26:1054-1059.
10 +
Lee CY:  Elapid neurotoxins and their mode of action . Clin Toxicol 1970;;3:457-472.
11 +
Bender AN, Ringel SP, Engel WK:  Immunoperoxidase localization of alpha bungarotoxin: A new approach to myasthenia gravis . Ann NY Acad Sci 1976;;274:20-30.
12 +
Mittag TW, Caroscio J:  False-positive immunoassay for acetylcholine-receptor antibody in amyotrophic lateral sclerosis . N Engl J Med 1980;;302:868.
13 +
Chang CC, Lee CY:  Isolation of neurotoxins from the venom of Bungarus multicinctus and their modes of neuromuscular blocking action . Arch Int Pharmacodyn Ther 1963;;144:241-257.
14 +
Seybold ME, Lindstrom JM:  Immunopathology of acetylcholine receptors in myasthenia gravis . Springer Semin Immunopathol 1982;; 5:389-412.
15 +
Fumagalli G, Engel AG, Lindstrom J:  Estimation of degration rate of acetylcholine receptor by external gamma counting in vivo . Mayo Clin Proc 1982;;57:758-764.
16 +
Patrick J, Lindstrom J:  Autoimmune response to acetylcholine receptor . Science 1973;;180:871-872.
17 +
Seybold ME, Lambert EH, Lennon VA, et al:  Experimental autoimmune myasthenia: Clinical, neurophysiologic, and pharmacologic aspects . Ann NY Acad Sci 1976;;274:275-282.
18 +
Lambert EH, Lindstrom JM, Lennon VA:  End-plate potentials in experimental autoimmune myasthenia gravis in rats . Ann NY Acad Sci 1976;;274:300-318.
19 +
Engel AG, Tsujihata M, Lindstrom JM, et al:  The motor endplate in myasthenia gravis and in experimental autoimmune myasthenia gravis: A quantitative ultrastructural study . Ann NY Acad Sci 1976;;274:60-79.
20 +
Engel AG, Sakakibara H, Sahashi K, et al:  Passively transferred experimental autoimmune myasthenia gravis: Sequential and quantitative study of the motor end-plate fine structure and ultrastructural localization of immune complexes (IgG and C3), and of the acetylcholine receptor . Neurology 1979;;29:179-188.
21 +
Lindstrom JM, Lambert EH:  Content of acetylcholine receptor and antibodies bound to receptor in myasthenia gravis, experimental autoimmune myasthenia gravis, and Eaton-Lambert syndrome . Neurology 1978;; 28:130-138.
22 +
Engel AG, Lambert EH, Howard FM Jr:  Immune complexes (IgG and C3) at the motor end-plate in myasthenia gravis: Ultrastructural and light microscopic localization and electrophysiologic correlations . Mayo Clin Proc 1977;;52:267-280.
23 +
Sahashi K, Engel AG, Lambert EH, et al:  Ultrastructural localization of the terminal and lytic ninth complement component (C9) at the motor end-plate in myasthenia gravis . J Neuropathol Exp Neurol 1980;; 39:160-172.
24 +
Lennon VA, Seybold ME, Lindstrom JM, et al:  Role of complement in the pathogenesis of experimental autoimmune myasthenia gravis . J Exp Med 1978;;147:973-983.
25 +
Lennon VA, Lambert EH:  Monoclonal autoantibodies to acetylcholine receptors: Evidence for a dominant idiotype and requirement of complement for pathogenicity . Ann NY Acad Sci 1981;;377:77-95.
26 +
Tzartos SJ, Rand DE, Einarson BL, et al:  Mapping of surface structures of electrophorus acetylcholine receptor using monoclonal antibodies . J Biol Chem 1981;;256:8635-8645.
27 +
Tzartos SJ, Seybold ME, Lindstrom JM:  Specificities of antibodies to acetylcholine receptors in sera from myasthenia gravis patients measured by monoclonal antibodies . Proc Natl Acad Sci USA 1982;;79:188-192.
28 +
Lindstrom JM, Tzartos S, Gullick W:  Structure and function of the acetylcholine receptor molecule studied using monoclonal antibodies . Ann NY Acad Sci 1981;;377:1-19.
29 +
Almond RR, Andrew CG, Appel SH:  Serum globulin in myasthenia gravis: Inhibition of α-bungarotoxin binding to acetylcholine receptors . Science 1974;;186:55-57.
30 +
Lennon VA:  Myasthenia gravis: Diagnosis by assay of serum antibodies . Mayo Clin Proc 1982;;57:723-724.
31 +
Desouki A, Eldefrawi AT, Eldefrawi ME:  A new mechanism revealed for the action of antibodies on acetylcholine receptor function . Exp Neurol 1981;;73:440-450.
32 +
Drachman DB, Adams RN, Stanley EF:  Mechanisms of acetylcholine receptor loss in myasthenia gravis . J Neurol Neurosurg Psychiatry 1980;;43:601-610.
33 +
Christadoss P, Lennon VA, Krco CG, et al:  Genetic control of autoimmunity to acetylcholine receptors: Role of Ia molecules . Ann NY Acad Sci 1981;;377:258-276.
34 +
Waldor MK, Sriram S, McDevitt HO, et al:  In vivo therapy with monoclonal anti I-A antibody suppresses immune responses to acetylcholine receptor . Proc Natl Acad Sci USA 1983;;80:1713-1717.
35 +
DeBaets MH, Einarson B, Lindstrom JM, et al:  Lymphocyte activation in experimental autoimmune myasthenia gravis . J Immunol 1982;; 128:2228-2235.
36 +
Newsom-Davis J, Willcox N, Calder L:  Thymus cells in myasthenia gravis selectively enhance production of anti-acetylcholine-receptor antibody by autologous blood lymphocytes . N Engl J Med 1981;;305:1313-1318.
37 +
Koethe SM, Cook A, McQuillen DP, et al:  Clinical and immunologic correlations in myasthenia gravis: Measurements of Con A stimulated suppressor cell activity . Ann NY Acad Sci 1981;;377:447-453.
38 +
Seybold M, Tsoukas C, Lindstrom J, et al:  Leukoplasmapheresis for myasthenia gravis . Arch Neurol 1982;;39:433-435.
39 +
Harfast B, Huddlestone JR, Braheny S, et al:  Myasthenia gravis: In vitro immunoglobulin production with pokeweed mitogen challenge and B- and T-lymphocyte competence . Clin Immunol Immunopathol 1981;;20:336-345.
40 +
Noguchi SA, Drachman DB, Adams RN, et al:  Lymphocyte responsiveness to acetylcholine receptor in rats with experimental autoimmune myasthenia gravis . Ann Neurol 1980;;8:32-37.
41 +
Gardner JM, Fambrough DM:  Acetylcholine receptor degradation measured by density labeling: Effects of cholinergic ligands and evidence against recycling . Cell 1979;;16:661-674.
42 +
Grob D, Brunner NG, Namba T:  The natural course of myasthenia gravis and effect of therapeutic measures . Ann NY Acad Sci 1981;; 377:652-669.
43 +
Blalock A:  Tumors of the thymic region and myasthenia gravis . Am J Surg 1941;;57:149-150.
44 +
Buckingham JM, Howard FM Jr, Bernatz PE, et al:  The value of thymectomy in myasthenia gravis: A computer-assisted matched study . Ann Surg 1976;;184:453-458.
45 +
Seybold ME, Howard FM Jr, Duane DD, et al:  Thymectomy in juvenile myasthenia gravis . Arch Neurol 1971;;25:385-392.
46 +
Rodriguez M, Gomez MR, Howard FM Jr, et al:  Myasthenia gravis in children: Long-term follow-up . Ann Neurol 1983;;13:504-510.
47 +
Scadding GK, Webster ADB, Ross M, et al:  Humoral immunity before and after thymectomy in myasthenia gravis . Neurology 1979;; 29:502-506.
48 +
Seybold ME, Lindstrom JM:  Patterns of acetylcholine receptor antibody fluctuation in myasthenia gravis . Ann NY Acad Sci 1981;; 377:292-305.
49 +
Seybold ME, Baergen RN, Nave B, et al:  Anti-acetylcholine receptor antibody concentrations after thymectomy in patients with myasthenia gravis . Br Med J 1978;;2:1051-1053.
50 +
Grob D, Namba T:  Corticotropin in generalized myasthenia gravis: Effect of short, intensive courses . JAMA 1966;;198:703-707.
51 +
Osserman KE, Genkins G:  Studies in myasthenia gravis: Short-term massive corticotropin therapy . JAMA 1966;;198:699-702.
52 +
Seybold ME, Drachman DB:  Gradually increasing doses of prednisone in myasthenia gravis: Reducing the hazards of treatment . N Engl J Med 1974;;290:81-84.
53 +
Howard FM Jr, Duane DD, Lambert EH, et al:  Alternate-day prednisone: Preliminary report of a double-blind controlled study . Ann NY Acad Sci 1976;;274:596-607.
54 +
Kornfeld P, Genkins G, Papatestas AE, et al:  Steroid therapy in myasthenia gravis associated with thymoma . Mt Sinai J Med 1978;; 45:106-115.
55 +
Morgutti M, Conti-Tronconi BM, Sghirlanzoni A, et al:  Cellular immune response to acetylcholine receptor in myasthenia gravis: II. Thymectomy and corticosteroids . Neurology 1979;;29:734-738.
56 +
Abramsky O, Tarrab-Hazdai R, Aharonov A, et al:  Immunosuppression of experimental autoimmune myasthenia gravis by hydrocortisone and azathioprine . J Immunol 1976;;117:225-228.
57 +
Sanders DB, Johns TR, Eldefrawi ME, et al:  Experimental autoimmune myasthenia gravis in rats: Modification by thymectomy and prednisolone . Arch Neurol 1977;;34:75-79.
58 +
Mertens HG, Hertel G, Reuther P, et al:  Effect of immunosuppressive drugs (azathioprine) . Ann NY Acad Sci 1981;;377:691-698.
59 +
Lefvert AK, Matell G:  Antibodies against human cholinergic receptor proteins in patients with myasthenia gravis: Studies during immunosuppressive treatment . Acta Med Scand 1977;;201:181-182.
60 +
Reuther P, Fulpius BW, Mertens HG, et al:  Anti-acetylcholine receptor antibody under long-term azathioprine treatment in myasthenia gravis , in Dau PC (ed): Plasmapheresis and the Immunobiology of Myasthenia Gravis . Boston, Houghton Mifflin Co, 1979;, pp 329-342.
61 +
Pestronk A, Drachman DB:  Therapeutic strategies in experimental autoimmune myasthenia gravis . Ann NY Acad Sci 1981;;377:278-290.
62 +
Bergstrom K, Franksson C, Matell G, et al:  The effect of thoracic duct lymph drainage in myasthenia gravis . Eur Neurol 1973;;9:157-167.
63 +
Pinching AJ, Peters DK, Newsom-Davis J:  Remission of myasthenia gravis following plasma exchange . Lancet 1976;;2:1373-1376.
64 +
Dau P:  Response to plasmapheresis and immunosuppressive therapy in sixty myasthenia gravis patients . Ann NY Acad Sci 1981;;377:700-708.
65 +
Hawkey CJ, Newsom-Davis J, Vincent A:  Plasma exchange and immunosuppressive drug treatment in myasthenia gravis: No evidence for synergy . J Neurol Neurosurg Psychiatry 1981;;44:469-475.
66 +
Nielson VK, Paulson OB, Rosenkvist J:  Rapid improvement of myasthenia gravis after plasma exchange . Ann Neurol 1982;;11:160-169.
67 +
Olarte MR, Schoenfeldt RS, Penn AS, et al:  Effect of plasmapheresis in myasthenia gravis 1978-1980 . Ann NY Acad Sci 1981;;377:725-728.

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BMJ 2010;341:c5893-c1494.
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