Mabalot,Mark Johann O.
BS BIOLOGY 4a
Catolico, Karen Faye
April ! "#$
%ra&era,Franci' Bene(erito, )e(orie Case Study: Animal Physiology Lecture Myasthenia Gravis Introduction
Mya'thenia Mya'thenia *ra+i' i' a chronic chronic atoi((ne atoi((ne nero('clar nero('clar -i'ea'e -i'ea'e characteri characteriee- by +aryin* +aryin* -e*ree' -e*ree' o/ 0eakne' 0eakne''' o/ the 'kelet 'keletal al 1+oln 1+olntar tary2 y2 ('cle ('cle'' o/ the bo-y. bo-y. %he na(e na(e (ya'thenia *ra+i', 0hich i' Latin an- Greek in ori*in, literally (ean' 3*ra+e ('cle 0eakne''.3 ith crrent therapie', ho0e+er, (o't ca'e' o/ (ya'thenia *ra+i' are not a' 3*ra+e3 a' the na(e i(plie'. In /act, (o't in-i+i-al' 0ith (ya'thenia *ra+i' ha+e a nor(al li/e e5pectancy 1%arto' et al., #6672. al., #6672. %he hall(ark o/ (ya'thenia (ya'thenia *ra+i' i' ('cle ('cle 0eakne'' 0eakne'' that increa'e' increa'e' -rin* -rin* perio-' perio-' o/ acti+ity an- i(pro+e' a/ter perio-' o/ re't. Certain ('cle' 'ch a' tho'e that control eye aneyeli- (o+e(ent, /acial e5pre''ion, che0in*, talkin*, an- '0allo0in* are o/ten, bt not al0ay', in+ol+e- in the -i'or-er. %he ('cle' that control breathin* an- neck an- li(b (o+e(ent' (ay al'o be a//ecte-. Description
Mya'thenia *ra+i' 1MG2 i' a lon*8ter( nero('clar -i'ea'e that lea-' to +aryin* -e*ree' o/ 'keletal ('cle 0eakne''. %he (o't co ((only a//ecte- ('cle' are tho'e o/ the eye', e ye', /ace, an- '0allo0in*. It can re'lt in -ob le +i'ion, -roopin* eyeli-', troble talkin*, an- troble
0alkin*. On'et can be '--en. %ho'e a//ecte- o/ten ha+e a lar*e thy(' *lan- or -e+elop a thy(o(a 1Archi+e' o/ )erolo*y, "#2. Mya'thenia *ra+i' i' an atoi((ne -i'ea'e 0hich re'lt' /ro( antibo-ie' that block or -e'troy nicotinic acetylcholine receptor' at the &nction bet0een the ner+e an- ('cle. %hi' pre+ent' ner+e i(pl'e' /ro( tri**erin* ('cle contraction'.9arely, an inherite- *enetic -e/ect in the nero('clar &nction re'lt' in a 'i(ilar con-ition kno0n a' con*enital (ya'thenia.Babie' o/ (other' 0ith (ya'thenia (ay ha+e 'y(pto(' -rin* their /ir't /e0 (onth' o/ li/e, kno0n a' neonatal (ya'thenia. :ia*no'i' can be 'pporte- by bloo- te't' /or 'peci/ic antibo-ie', the e-rophoni( te't, or ner+e con-ction 't-ie'. Mya'thenia *ra+i' i' *enerally treate- 0ith (e-ication' kno0n a' acetylcholine'tera'e inhibitor' 'ch a' neo'ti*(ine an- pyri-o'ti*(ine. I((no'ppre''ant', 'ch a' pre-ni'one or aathio aathiopri prine, ne, (ay al'o al'o be 'e-. 'e-. %he 'r*ical 'r*ical re(o+al re(o+al o/ the thy(' thy(' *lan- (ay i(pro+ i(pro+ee 'y(pto(' 'y(pto(' in certain certain ca'e'. ca'e'. ;la'(aphere' ;la'(aphere'i' i' an- hi*h -o'e intra+eno' intra+eno' i((no*lobli i((no*loblin n (ay be 'e- -rin* '--en /lare' o/ the con-ition. I/ the breathin* ('cle' beco(e 'i*ni/icantly 0eak, (echanical +entilation (ay be re<ire-. Case History
Ca'e =#> A ?$8year8ol?$8year8ol- (an, co(plainin* co(plainin* o/ -oble +i'ion, 0a' /on- to ha+e bilateral pto'i', pto'i', co+erin* co+erin* (o't o/ the ppil on the ri*ht 'i-e an- partially ob'crin* that on the le/t. %he pto'i' 0a' 0or'e in the e+enin* an- al(o't ab'ent in the (ornin*. @e a-(itte- to tire-ne'' in the ar(' an- le*' on e5erci'e, 0hich reco+ere- 0ith re'tin*. A clinical -ia*no'i' o/ oclar (ya'thenia *ra+i' 0a' (a-e. (a-e. @i' %en'io en'ion' n' te't te't 0a' po'iti po'iti+e +e bt electr electro(y o(yo*ra o*raphy phy 0a' inconcl inconcl'i 'i+e. +e. @i' @i' 'er( 'er(
containe- antibo-ie' to thyroi- (icro'o(e' 1po'iti+e at ##?""2 an- to acetylcholine receptor'. %he patient i(pro+e- on treat(ent 0ith pyri-o'ti*(ine. Ca'e => A #8year8ol#8year8ol- 0o(an 0a' re/erre- to a nerolo*y clinic 0ith a #8(onth hi'tory o/ -oble +i'ion, -i//iclty '0allo0in* an- 0eakne'' in her pper ar('. %he'e 'y(pto(' 0ere (il- or ab'ent in the (ornin* an- ten-e- to 0or'en thro*h the -ay. hen 'he 0a' 'een to0ar-' the eno/ an a/ternoon nerolo*y clinic 'he 0a' /on- to ha+e a bilateral pto'i' an- -i'con&*ate eye (o+e(ent' that col- not be a'cribe- to any in-i+i-al cranial ner+e le'ion. @er pper li(b po0er 0a' initially nor(al bt -eteriorate- 0ith repeate- te'tin*. An intra+eno' in&ection o/ e-rophoni(, a 'hort8actin* choline'tera'e inhibitor, co(pletely aboli'he- the nerolo*ical 'i*n' bt her eye (o+e(ent' -eteriorate- a*ain "(in a/ter the in&ection. A clinical -ia*no'i' 0a' (a-e o/ (ya'thenia *ra+i'. Sb'e<ent bloo- te'tin* 'ho0e- the pre'ence o/ a hi*h le+el o/ antibo-ie' a*ain't the acetylcholine receptor. She 0a' treate- 0ith oral choline'tera'e inhibitor' 0ith 'o(e i(pro+e(ent. @o0e+er, # (onth (onth later later 'he -eteri -eteriora oratete- an- cortic cortico't o'teroi eroi-' -' 0ere 0ere introintro-cece- 0ith 0ith no i(pro+ i(pro+e(e e(ent. nt. A co(pte- to(o*raphy 'can o/ her thora5 'ho0e- no e+i-ence o/ a thy(o(a bt 'he 0a' ne+ert ne+erthel hele'' e'' re/err re/erree- to a thorac thoracic ic 'r*eo 'r*eon n /or thy(ec thy(ecto(y to(y a' thi' thi' can 'o(eti 'o(eti(e' (e' in-ce in-ce re(i''ion in (ya'thenia e+en in the ab'ence o/ a thy(o(a. A '(all thy(ic re(nant 0a' re(o+e- an- 'he reco+ere- ne+ent/lly an- 0a' able to 0ith-ra0 /ro( all (e-ication 0ithot -eteri -eteriora oratio tion n in her 'y(pto( 'y(pto('. '. Acety Acetylch lcholi oline ne recept receptor or antibo antibo-y -y le+el' le+el' /ell /ell bt re(ain re(ainee-etectable. One year later, 'he beca(e pre*nant an- a/ter an ne+ent/l 4#80eek pre*nancy 'he -eli+ere- a 48k* (ale in/ant. %here 0ere i((e-iate concern' abot the baby 0ho /aile- to (ake a-e<ate re'piratory e//ort' an- 0ho appeare- li(p an- hypotonic. %he baby 0a' intbate- an-
+entilate+entilate- on the neonatal inten'i+e inten'i+e care nit. In the li*ht o/ the (other' hi'tory hi'tory,, a pro+i'ional pro+i'ional -ia*no'i' o/ neonatal (ya'thenia *ra+i' 0a' (a-e, altho*h care 0a' taken to e5cl-e other ca' ca'e' e' o/ neon neonat atal al re'p re'pir irat atory ory in' in'// //ic icie iency ncy 'ch 'ch a' (ate (atern rnal al anal anal*e' *e'ia ia 0ith 0ith peth pethii-in ine, e, hypo*ly hypo*lycae( cae(ia ia an- 'ep'i' 'ep'i'.. A cranial cranial ltra' ltra'onon- 'ho0e'ho0e- no e+i-enc e+i-encee o/ blee-i blee-in* n* or other other patholo*y. Sb'e<ent te'tin* o/ a bloo- 'a(ple taken /ro( the (bilical cor- 'ho0e- lo0 le+el' le+el' o/ acetylc acetylchol holine ine recept receptor or antibo antibo-y -y.. %he baby nee-enee-e- +entil +entilati ation on an- /ee-in /ee-in* * +ia a na'o*a'tric tbe /or -ay' at 0hich ti(e the +entilation 0a' 'cce''/lly 0ith-ra0n. %here 0ere 'o(e initial /ee-in* proble(' -e to -i//iclty 'ckin* an- '0allo0in* bt the'e re'ol+e- o+er the ne5t 47h. %he chil-' 'b'e<ent -e+elop(ent ha' been entirely nor(al. %he (other al'o re(ain' 0ell. Etiology and Epidemiology
Mya'thenia Gra+i' 1MG2 i' a nero('clar -i'or-er that ca'e' ('cle 0eakne''. %he na(e Mya'thenia *ra+i' ca(e /ro( a Latin an- Greek 0or-' 0hich literally (ean' D*ra+e ('cle 0eakne''E. It 'ally a//ect' +olntary ('cle' or ('cle' that are can be controllecon'cio'ly. It i' characterie- by 0eakne'' o/ ('cle' 'ch a' oclar, neck, li(b', blbar anre'piratory. It i' not a per(anent 0eakne'' o/ ('cle bt it i' /lctatin* 0ithot lo'in* the re/le5 re/le5e' e' o/ 'en'at 'en'ation ion or other other nerol nerolo*ic o*ic /ncti /nction. on. %he 'y(pto( 'y(pto('' 0or'en 0or'en te(por te(porari arily ly ani(pro+e 0ith a re't. MG i' cla''i/ie- a' an atoi((ne -i'ea'e 0hich (ean' that the bo-y' i((ne 'y'te( attack' the connection bet0een the ner+e an- ('cle (i'takenly. %he 0eakne'' o/ the ('cle i' the re'lt 0hen the ('cle cell' cannot re'pon- properly to the ner+e i(pl'e' that 'i*nal' the( to contract 1%han+i an- Lo, ""72. Mya'thenia Mya'thenia *ra+i' a//ect' appro5i(ately appro5i(ately #"" patient' patient' per (illion (illion people 1Jacob et al., ""62. Accor-in* to Y et al., #676 al., #676 0o(en are (ore a//ecte- t0ice than (en bt it ha' no
'i*ni/icant *en-er -i//erence in inci-ence e5i't' be/ore pberty or a/ter the a*e o/ /orty. %hi' -ea'e' a//ect' all a*e *rop' an- peak' in a*e' t0enty an- thirty in 0o(en 0hile /i/ty an- 'i5ty year' ol- in (en 1Jacob et al., ""62. %he /ir't ca'e reporte- o/ MG i' a nati+e A(erican Chie/ Opechancano*h 0ho -ie- in #??4. It 0a' -e'cribe- a' an e5ce''i+e /ati*e 0ith (acerate/le'h. %he +i*ority ha' been lo't their tone an- ela'ticity. %he per'on i' not able to open hi' eyeli-' 'ince he /elt that it i' 'o hea+y an- he cannot 'ee nle'' hi' eyeli-' 0ere li/te- p by hi' atten-ant'. Frther(ore he cannot 0alk -e to 0eakne'' o/ hi' le* ('cle' 1Conti, ""?2. Mya'thenia *ra+i' i' con'i-ere- a' a 'erio' -i'ea'e bt can be treate-. %he /ati*ability o/ the +olntary ('cle' are ca'e- by atoantibo-ie atoantibo-ie'' a*ain't a*ain't the nicotinic acetylcholine acetylcholine receptor receptor 1ACh92 1ACh92 on the po't'y po't'ynapt naptic ic (e(bra (e(brane ne at the ('cl ('clar ar &ncti &nction on 1%art 1%arto' o' et al., al., #6672. %he antibo-ie' are pro-ce- by bo-y' o0n i((ne 'y'te( to protect it /ro( /orei*n or*ani'(' bt in Mya'thenia *ra+i', the'e antibo-ie' (i'takenly attack it. %hi' -i'ea'e i' ca'e- by a -e/ect in the tran'(i''ion o/ ner+e i(pl'e' to ('cle'. It take' place i/ the nor(al co((nication bet0een the ner+e an- ('cle i' interrpte- at the nero('clar &nction. )ero('clar &nction i' the place 0here ner+e cell' connect 0ith the ('cle' they inner+ate. Acetylcholine i' one o/ the nerotran'(itter in or brain cell' that i' 'e by the ner+o' 'y'te( to co((nicate co ((nicate 0ith other brain cell'. It i' /on- in the inter/ace bet0een the pre'ynaptic ner+e ter(inal an- po't'ynaptic ('cle (e(brane. Acetylcholine are relea'e- by ner+e en-in*' an- it tra+el' /ro( nero('clar &nction an- bin-' to acetylcholine receptor' 0hich are acti+ate- an- *enerate a ('cle contraction 1%han+i an- Lo, ""72. %he 'y(pto(' o/ MG incl-e' proble(' 0alkin* p'tair' or li/tin* ob&ect', paraly'i' o/ the /ace, -i//iclt -i//iclty y in talkin* talkin* an- breathin* -e to ('cle 0eakne'', troble in '0allo0in* '0allo0in* an-
che0in*, ha+in* a hoar'e +oice, -roopin* o/ eyeli-', /ati*e, an- -oble +i'ion 1@ern-on, "#?2. %hi' atoi((ne -i'ea'e i' al'o characterie- by> • • • • • •
Speci/ic ('cle 0eakne'' rather than *eneralie- 0eakne'' 5traoclar ('cle 0eakne'' or pto'i' Blbar ('cle 0eakne'' Li(b 0eakne'' in pro5i(al part' o/ the bo-y Se+erity o/ 0eakne'' i' co((on in the (ornin* an- 0or'en' a' the -ay pro*re'' eakne'' 'tart' /ro( oclar an- 'prea-' to /acial to blbar ('cle' an- then to trncal an- li(b ('cle' 1Shah et al., "#?2.
Mya' Mya'th then enia ia *ra+i *ra+i'' are are -i+i -i+i-e -e- into into /i+e /i+e (ain (ain cla' cla''e 'e'' an- 'e+e 'e+era rall 'bc 'bcla la'' ''e' e' by the the Mya'thenia Gra+i' Fon-ation o/ A(erica 1MFGA2 1Jaretky, """2. •
Cla'' I i' characterie- by oclar ('cle 0eakne''H inability to clo'e the eye'H other
•
('cle 'tren*th are nor(al Cla'' II 'ho0' 0eakne'' on other ('cle' o/ the eye'H eye ('cle 0eakne'' can be in
•
any 'e+erity Cla'' IIa i' characterie- by le''er in+ol+e(ent o/ oropharyn*eal ('cle' an- the li(b',
•
a5ial ('cle' or both are pre-o(inantly a//ecteCla'' IIb > the oropharyn*eal, re'piratory ('cle' or both are pre-o(inantly a//ecte-H
•
le''er in+ol+e(ent o/ li(b an- a5ial ('cle' Cla'' III MG 'ho0' (o-erate 0eakne'' o/ other oclar ('cle' an- can be at any
• •
• •
'e+erity Cla'' IIIa> A//ectin* A//ectin* li(b an- a5ial ('cle'H in+ol+e(ent o/ oropharyn*eal ('cle' Cla'' IIIb i' characteri characteriee- by a//ectea//ecte- oropharyn*eal oropharyn*eal an- re'piratory re'piratory ('cle'H ('cle'H le''er le''er or e<al in+ol+e(ent o/ li(b an- a5ial ('cle' Cla'' I 'ho0' 'e+ere 0eakne'' o/ ('cle' other than oclar an- can be at any 'e+erity Cla'' Ia> ;re-o(inantly a//ectin* li(b, a5ial ('cle' or bothH le''er in+ol+e(ent o/ oropharyn*eal ('cle'
•
Cla'' Ib i' characterie- by pre-o(inantly a//ecte- oropharyn*eal, re'piratory or bothH le''er or e<al in+ol+e(ent o/ li(b, a5ial ('cle' or bothH /ee-in* o/ a patient i' -one
•
thro*h tbe 0ithot intbation Cla' Cla''' > FeeFee-in in* * can can be -one -one 0ith 0ith the the 'e 'e o/ int intba bati tion0 on0it ith h or 0ith 0ithot ot (e-i (e-ica call +entilation
%he -i+i'ion o/ Mya'thenia *ra+i' 'y(pto(' i' -e'i*ne- to i-enti/y 'b*rop' o/ patient 0ho 'hare the 'a(e 'e+erity o/ o / -i'ea'e 0hich (ay in-icate -i//erent re'pon'e' to therapy 1%roth et al., "#2. Se+eral Se+eral /actor /actor'' colcol- tri**er tri**er an- 0or'en 0or'en the -i'ea' -i'ea'e. e. %he /ollo0 /ollo0in* in* /actor /actor'' are> are> Bri*ht Bri*ht 'nli*ht, 'r*ery, i((niation, i((niation, e(otional 'tre'', (en'tration, intercrrent -i'ea'e 'ch a' +iral in/ect in/ection ion an- (e-ica (e-icatio tion' n' 1a(ino 1a(ino*ly *lyco' co'i-e i-e', ', cipro/ cipro/lo5 lo5aci acin, n, chloro chloro<i <ine, ne, procai procaine, ne, lithi( lithi( phenytoin, beta8blocker', procaina(i-e an- 'tatin'2 1Shah et al., "#?2. Diagnosis
Many -i'or-er' can ca'e 0eakne'' o/ ('cle', Mya'thenia Gra+i' i' one o/ the(. %he -ia*no'i' o/ Mya'thenia Gra+i' 'hol- be (a-e by a nerolo*i't. Accor-in* to the 't-y o/ A(erican Aca-e(y o/ )erolo*y 1"#?2 the e+alation (ay incl-e (e-ical an- nerolo*ic e+alation, Bloo- te't' to check /or antibo-ie', Bloo- te't' or other 't-ie' to rle ot other ca' ca'e' e' o/ 0eakne 0eakne'' '',,
i(a*i i(a*in* n* 'can' 'can',,
elec electr trica icall te't' te't' o/ ner+e ner+e an- ('cl ('clee /nct /nctio ion n
1electro(yo*raphy an- ner+e con-ction 't-ie'2, an- Ice pack te't to i(pro+e 'tren*th o/ the eyeli-. A pro+i' pro+i'ion ional al -ia*no' -ia*no'i' i' (ay be (a-e 'in* 'in* the e-roph e-rophoni oni( ( te't te't or %on'il on'ilon on te't te't 1Matthe0, ""42, a -r* calle- %on'ilon or a -((y (e-icine 1inacti+e placebo2 i' *i+en -rin* thi' te't. %he health care pro+i-er *i+e' the appropriate one thro*h one o/ the patient' +ein', the acti action on o/ %on'il n'ilon on -r* -r* incl incl-ee
inhi inhibi bit' t' acet acetyl ylch chol olin ine' e'te tera ra'e 'e,,
prol prolon on*' *' pre' pre'en ence ce o/
nerotran'(i nerotran'(itter tter,, acetylcholine acetylcholine,, in the nero(a'cla nero(a'clarr &nction, &nction, an- re'lt' re'lt' in enhanceenhance- ('cle ('cle 'tren*th. %he patient i' MG po'iti+e po'iti+e i/ (o't o/ (ya'thenic ('cle' ('cle' re'pon- in " to 4! 'econ-' a/ter in&ection, i(pro+e(ent in 'tren*th that (ay per'i't /or p to ! (inte', an- re<ire' ob&e ob&ect cti+ i+ee i(pr i(pro+e o+e(e (ent nt in ('c ('cle le 'tre 'tren*t n*th h 1Arc 1Archi hi+e' +e' o/ )er )erol olo*y o*y,, "#2 "#2 pati patient ent 0ith 0ith Mya'thenia *ra+i' /re<ently ha+e other -i'ea'e that ha+e pre'(e- or kno0n i((nolo*ical ca'e 'ch a' thyroi- -i'ea'e, rhe(atoi- arthriti', an- +ita(in B# -e/iciency 1@o0ar-, ""72. reatment
Mo-ern treat(ent o/ (ya'thenia *ra+i' i' hi*hly e//ecti+e. Accor-in* to the re'earch o/ %han+i 1""42 the /ollo0in* treat(ent (o-alitie' are a+ailable> acetylcholine'tera'e inhibitor' 8 the' the'ee -r*' -r*' act act by inhi inhibi biti tin* n* acety acetylc lcho holi line' ne'te tera ra'e 'e anan- th' th' incr increa ea'e 'e a+ai a+aila labi bili lity ty o/ the the acetylcholine to act on the ACh receptor'. %hey are 'ally the initial -r*' 'e- in the treat(ent o/ (ya'thenia *ra+i' an- (ay the only -r* re<ire- to treat (il- -i'ea'e, cortico'teroi-', i((no'ppr i((no'ppre''ant e''ant', ', pla'(aphere' pla'(aphere'i', i', intra+eno' intra+eno' i((no*obl i((no*oblin', in', an- thy(ecto(y thy(ecto(y.. %he treat(ent o/ (ya'thenia *ra+i' can be con'i-ere- to in+ol+e three 'tep'> 1#2 initial treat(ent 'ally in+ol+e' 'e o/ the acetylcholine'tera'e inhibitor'. @o0e+er, the'e -r*' are 'ally not a-e<ate to control -i'ea'e on their o0n an- an a--itional therapy i' (o'tly nee-e-. 12 O/ten an i(( i((ne ne -ire -irect ctee- treat treat(e (ent nt i' a--ea--e-,, be*i be*inn nnin in* * 0ith 0ith eith either er thy( thy(ect ecto(y o(y or hi*h hi*h -o'e -o'e cortico'teroi-'. 12 In the lon* ter(, 'teroi-8'parin* (e-ication' are 'ally a--e- to /acilitate the taperin* pha'e. Short ter( therapie', intra+eno' i((no*loblin or pla'(aphere'i', (ay be e//ecti+e in the early 'ta*e' o/ treat(ent, be/ore thy(ecto(y, or later -rin* an e5acerbation 1%han+i, ""42. 9e/erence'> Archi+e' o/ )erolo*y."#. )erolo*y."#. MYAS%@ MYAS%@)IA )IA G9AI G9AIS> S> :IAG)OS%IC %S%S. 9etrie+e- /ro( http>nero('clar.0'tl.e-(ti(e(*-5.ht(l
A(erican Aca-e(y o/ )erolo*y. "#?. n-er'tan-in* Mya'thenia Gra+i'. 9etrie+e- /ro( htt p>patient'.aan.co(*lobal'a5ona''et'6!7.p-/ Conti8Fine B. M., M. Milani, an- @. J. Ka(in'ki.""?. DMya'thenia *ra+i'> pa't, pre'ent, an/tre,E Journal /tre,E Journal of Clinical Investigation, Investigation, +ol. ##?, no. ##, pp. 747!4 @ern-on J. "#?. Mya'thenia *ra+i'. @ealthline Me-ia. ni+er'ity o/ Illinoi'8Chica*o, Colle*e o/ Me-icine. 9etrie+e- /ro( 000.healthline.co(health(ya'thenia8*ra+i' @o0ar-, J. F. ""7. Mya'thenia Gra+i'> A Manal /or @ealth Care ;ro+i-er. Mya'thenia Gra+i' Fon-ation o/ A(erica. ISB)> "67#777"! Jacob S., S. ie*a', :. La'hley :. @. Jone'. ""6. Mya'thenia *ra+i' an- other nero('clar &nction -i'or-er'. )erolo*y in ;ractice. %he Bare ''ential'. 6>?4. -oi> #".##?&nnp.""6.#66# Jaretki, Jaretki, A. 9. J. Barohn, 9. M. rn'to// rn'to// et al., DMya'thenia DMya'thenia *ra+i'> *ra+i'> reco((en-ation' reco((en-ation' /or clinical clinical re'earch 'tan-ar-',E 'tan-ar-',E Annals of Thoracic Surgery, Surgery, +ol. $", no. #, pp. $4, """. Matthe0, M. ). :onal- S. B. ""4. Mya'thenia Gra+i'> :ia*no'i'. :epart(ent o/ Me-icine, :i+i'ion o/ )erolo*y, :ke ni+er'ity Me-ical Center, :rha(, )orth Carolina. 9etrie+e- /ro( http>#?.#$7.#".#$?aibc-oc(ento'-ia*no'tico-e(*.pShah, A., F. Fana ). Loreno. "#?. Mya' Mya'tthenia nia *ra+i'. Me-'c -'cape :r*' :i'ea'e')erolo*y. 9etrie+e- /ro( 000.(e-'cape.co(car-iolo*y 000.(e-'cape.co(car-iolo*y %roth A. J., A. :abi, n. Solie(an, M. Krk(bi J. Kalyana(. "#. 9e+ie0 Article Mya'thenia Gra+i'> A 9e+ie0. @in-a0i ;bli'hin* Corporation. Atoi((ne :i'ea'e'. ol(e ol(e "#, Article I: 7$4?7", -oi>#".##!!"#7$4?7" %han+i, B. 9. ""4. p-ate on Mya'thenia Gra+i'. :epart(ent o/ Inte*rate- Me-icine, Leice'ter 9oyal In/ir(ary, ni+er'ity @o'pital' o/ Leice'ter. :OI> #".##?p*(&.""4."#76" %han+i, B. 9. %. C. Lo. ""7. p-ate on Mya'thenia Gra+i'. -oi> #".##?p*(&.""4."#76". pp ?6"8$"". %arto' SJ, Barka' %, Cn* M%, et al. #667. Anato(y o/ the anti*enic 'trctre o/ a lar*e (e(brane atoanti*en, the ('cle8type nicotinic acetylcholine receptor.I((nolH#?>76#" YYL, YYL, @a0kin' B9, on* C), et al. %he @on* Kon* Mya'thenia Gra+i' :ata Bank. J Bank. J Hong Kong Med Assoc. #676H4#>!68?!.
