Clinical Manifestations

The single most important clinical feature of myasthenia gravis is weakness of skeletal muscle worsened by exercise and relieved by rest. Without this feature there can be no diagnosis. Weakness with easy fatigability is the only constant in this disease; all other features are variable. For instance, the weakness is usually worse in the afternoon and evening, although some patients are weaker in the morning when they first awaken. Usually the muscles supplied by the cranial nerves are the first and most severely affected, with resultant diplopia, ophthalmoplegia, dysphagia, dysphonia, dyspnea, and dys-mimia. The disease may involve proximal lower- and upper-extremity muscles. In rare instances, however, proximal muscles weaken first. Involvement of individual muscles may be symmetrical, but is often asymmetrical with a dominant leg and arm usually weaker than a nondominant counterpart. Myasthenia gravis can also present as weakness of a single muscle - for example, the external rectus or superior oblique in one eye - or as a single complaint - for instance, jaw ptosis from inability to close the mouth. It can also present as a symptom seemingly unrelated to the neuromuscular system - for instance, burning eyes from exposure to keratitis, from incomplete eye closure during sleep, or a sore throat on awakening from mouth breathing during sleep. The disease may affect people at any age or of either sex and varies in severity from mild nonprogressive disease involving the eyes only (ocular form) to severe cases that may be rapidly fatal such as acute myasthenia gravis afflicting older men.

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