title: The natural history and ophthalmic involvement in childhood myasthenia gravis at the hospital for sick children.
abstract: OBJECTIVE
  To characterize signs, symptoms, and the natural history of myasthenic syndromes in pediatric patients.
  
  
  METHODS
  Retrospective noncomparative case series.
  
  
  METHODS
  Thirty-four patients with a diagnosis of myasthenia were identified from either the hospital's or treating physician's database.
  
  
  METHODS
  Retrospective chart review, clinical examination, and telephone interview.
  
  
  METHODS
  Information pertaining to the ophthalmologic and neurologic examination, diagnostic interventions, and treatment was noted. Patients with active disease, attending during the study period, were examined at their outpatient visits. Those who no longer attended the hospital were contacted by means of a telephone interview to complete their follow-up.
  
  
  RESULTS
  Thirty-four children were found to have myasthenia. Two had transient neonatal myasthenia, which resolved quickly. Seven (20.6%) patients had congenital myasthenic syndromes (CMS) and 25 (73.5%, 19 females) were affected with autoimmune myasthenia gravis (AMG). In those patients with severe CMS, three showed signs of generalized weakness, including failure to thrive, frequent apneas, and aspirations. In four patients with mild CMS, eye signs were relatively more prominent. In all patients with CMS, strabismus, ophthalmoplegia, and ptosis were the main ophthalmologic signs and remained relatively constant. Fourteen (56%) patients with AMG had ocular signs and symptoms, and five of them progressed to systemic involvement in 7.8 months on average (range, 1-23). The remaining nine patients with ocular AMG had either strabismus or ptosis and were treated with pyridostigmine (nine patients) and prednisone (two patients). Patients with ocular AMG were seen at 78 months on average, those with systemic AMG at 85.6 months. Systemic AMG was seen in 16 patients. No thymomas were found in 14 patients who underwent thymectomy. Of the 25 patients with AMG, 8 are still being treated, 8 are in remission for an average of 65.2 months and are asymptomatic, 4 patients are receiving long-term immunosuppressants (1 has likely sustained permanent damage to her extraocular muscles with complete ophthalmoplegia and ptosis), and 4 have been lost to follow-up. Finally, one patient died after aspiration because of bulbar weakness.
  
  
  CONCLUSIONS
  Patients with CMS varied in the degree of severity. Apneic attacks, aspiration, and failure to thrive may obscure the diagnosis. Compared with AMG, their ophthalmologic signs and symptoms were usually permanent. Visual signs and symptoms were usually prominent in those patients with active AMG, but those in remission were asymptomatic. More than half of the patients with juvenile AMG had ocular symptoms. Generalization occurred in a minority in an average of 7.8 months. Patients entered remission after approximately 2 years of treatment and were visually asymptomatic. This study suggests that long-term permanent damage to the extraocular muscles as a result of juvenile AMG is rare. Myasthenia gravis is a life-threatening disease as evidenced by the death of one of our patients. Many of these patients are first seen by the ophthalmologist who can aid the diagnosis, screen for amblyopia, and monitor the patient's response to therapy.
authors.affiliation: Department of Ophthalmology, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: P
authors.initials: P
authors.lastname: Mullaney
authors.forename: J
authors.initials: J
authors.lastname: Vajsar
authors.forename: R
authors.initials: R
authors.lastname: Smith
authors.forename: J R
authors.initials: JR
authors.lastname: Buncic
mesh_terms: D000293:Adolescent; D001763:Blepharoptosis / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology; D002648:Child; D002675:Child, Preschool; D002800:Cholinesterase Inhibitors / Q000627:therapeutic use; D018450:Disease Progression; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009157:Myasthenia Gravis / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology; D020941:Myasthenia Gravis, Neonatal / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology; D020294:Myasthenic Syndromes, Congenital / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology; D009864:Ontario; D009886:Ophthalmoplegia / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology; D011241:Prednisone / Q000627:therapeutic use; D011729:Pyridostigmine Bromide / Q000627:therapeutic use; D012189:Retrospective Studies; D013285:Strabismus / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology
chemical_list: D002800:Cholinesterase Inhibitors; D005938:Glucocorticoids; D011729:Pyridostigmine Bromide; D011241:Prednisone