ARTICLE

Clinical Characteristics of Pediatric Myasthenia:

A Surveillance Study
AUTHORS: Juliana VanderPluym, MD,a Jiri Vajsar, MD,b WHAT’S KNOWN ON THIS SUBJECT: Pediatric myasthenia
Francois Dominique Jacob, MD,a Jean K. Mah, MD,c encompasses a group of rare and underdiagnosed conditions
Danielle Grenier, MD,d and Hanna Kolski, MDa affecting the neuromuscular junction. Symptoms include
aDivision of Neurology, Department of Pediatrics, University of fluctuating skeletal muscle weakness, which can progress to
Alberta, Edmonton, Alberta, Canada; bDivision of Neurology, respiratory failure if left untreated. The autoimmune form of this
Department of Pediatrics, SickKids and University of Toronto, condition, in particular, is treatable.
Toronto, Ontario, Canada; cDivision of Neurology, Department of
Pediatrics, University of Calgary, Calgary, Alberta, Canada; and
dCanadian Pediatric Society, Ottawa, Ontario, Canada WHAT THIS STUDY ADDS: This study describes the incidence,
KEY WORDS
clinical features, diagnostic testing, and treatment trends of
myasthenia gravis, congenital myasthenic syndromes, incidence pediatric myasthenia in Canada, which have not been previously
ABBREVIATIONS
reported in the literature.
AChR—acetylcholine receptor
CMS—congenital myasthenic syndromes
CPSP—Canadian Paediatric Surveillance Program
IVIg—intravenous immunoglobulin
JMG—juvenile myasthenia gravis
MuSK—muscle-specific kinase abstract
Dr VanderPluym carried out the data analyses and drafted the OBJECTIVE: To evaluate the incidence, clinical features, diagnostic, and
initial manuscript; Dr Vajsar collaborated on the study design, treatment trends of pediatric myasthenia in Canada.
obtained funding, and reviewed the manuscript; Dr Jacob
participated in the design of the study and the data collection METHODS: Through established Canadian Pediatric Surveillance Pro-
instruments and reviewed and revised the manuscript; Dr Mah gram methodology, physicians were anonymously surveyed for cases
collaborated on the study design, contributed to data collection,
and reviewed the manuscript; Dr Grenier reviewed and
of pediatric myasthenia using a standardized clinical questionnaire
commented on the initial study protocol and detailed containing deidentified data. Inclusion criteria were any child ,18
questionnaire and reviewed and the revised the manuscript; Dr years old with $1 of the following: (1) fluctuating ptosis or extra-
Kolski conceptualized and designed the study, obtained funding,
ocular weakness, (2) skeletal muscle weakness or fatigue, and (3) any
and reviewed and revised the manuscript; and all authors
approved the final manuscript as submitted. of the following supportive tests: clinical response to acetylcholines-
www.pediatrics.org/cgi/doi/10.1542/peds.2013-0814 terase inhibitor, positive antibodies, abnormal slow repetitive nerve
doi:10.1542/peds.2013-0814
stimulation, or single-fiber electromyography.
Accepted for publication Jul 2, 2013 RESULTS: In 2 years of surveillance, 57 confirmed cases were reported.
Address correspondence to Dr Juliana VanderPluym, Department There were 34 generalized and 18 ocular reports of juvenile myasthe-
of Pediatric Neurology, University of Alberta, 3-574A ECHA 11405- nia gravis plus 5 congenital myasthenic syndrome cases. There were 14
87 Ave, Edmonton, AB T6G 1C9, Canada. E-mail: juliana. incident cases in 2010 and 6 in 2011. Age of onset ranged from “birth”
[email protected]
to 17 years for the generalized form compared with 18 months to 11
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
years for the ocular subtype. Positive acetylcholine receptor titers
Copyright © 2013 by the American Academy of Pediatrics were found in 22 (67%) of 33 generalized cases and 8 (44%) of 18
FINANCIAL DISCLOSURE: The authors have indicated they have ocular patients. Of patients started on pyridostigmine, improvement
no financial relationships relevant to this article to disclose.
was noted in 33 (100%) of 33 generalized cases and 15 (88%) of 17
FUNDING: The authors gratefully acknowledge the monetary
ocular cases.
support of the Tara and Bobby Disenhouse Fund (Sick Kids
Foundation, Toronto, Canada), Myasthenia Gravis Ontario CONCLUSIONS: This study represents the largest descriptive series of
Chapter- Muscular Dystrophy Canada, an unrestricted pediatric myasthenia in North America and provides valuable informa-
educational grant from Talecris Biotherapeutics, and
a University of Alberta subspecialty residents research grant. tion about clinical characteristics. A high index of suspicion is impor-
POTENTIAL CONFLICT OF INTEREST: The authors have indicated
tant for this treatable disease. Children generally respond promptly to
they have no potential conflicts of interest to disclose. readily available therapies. Pediatrics 2013;132:e939–e944

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Pediatric myasthenia, first described by The CMS represent a group of rare ge- and pediatric subspecialists, including
Erb in 1879,1 is a heterogeneous group of netic conditions affecting proteins neurologists, are surveyed by the CPSP
acquired and genetic conditions of the expressed at the neuromuscular junc- on a monthly basis for cases.
neuromuscular junction. These rare and tion. They have been classified based on The initial “check-form” is returned on
underrecognized disorders are classi- the site of neuromuscular transmission a monthly basis to the CPSP office even
fied broadly into 3 categories: juvenile defect: presynaptic, postsynaptic, or if no new cases are identified. A detailed
myasthenia gravis (JMG), congenital synaptic. Clinical features may include clinical questionnaire is completed for
myasthenic syndromes (CMS), and hypotonia, limb contractures, and de- reported cases to gather additional
transient neonatal myasthenia gravis. layed motor milestones in children with anonymous information about patient
JMG is the most common myasthenic weak and small underdeveloped mus- demographics, family medical history,
disorder affecting children, represent- cles. In some cases, the presentation clinical presentation, investigations,
ing 10% to 15% of all myasthenia gravis may mimic congenital myopathies, initial treatments, and short-term out-
muscular dystrophies, or metabolic come for the patient. During 2010 and
cases in North America2 and up to 50%
myopathies.7 2011, the CPSP overall reporting rate
of cases from Asia.3 JMG encompasses
a group of autoimmune antibody- The diagnosis of myasthenic disorders in was 80% for the initial “check-form” and
mediated disorders targeting neuro- children is based mainly on clinical 86% for the detailed questionnaire.
muscular junction proteins, preventing presentation and supported by serum Research ethics board approval for this
nerve impulse transmission to muscle. antibody testing, genetic testing, positive study was obtained through the Uni-
The most commonly identified anti- edrophonium chloride (Tensilon) test- versity of Alberta Health Research Ethics
bodies target the acetylcholine recep- ing, and/or abnormal electrodiagnostic Board.
tors (AChRs) or, more rarely, the studies, including single-fiber electro-
Patients were considered eligible for
myography and/or repetitive nerve
muscle-specific kinase (MuSK) recep- inclusion if they were ,18 years old
stimulation. These conditions are often
tors. The clinical hallmark of the dis- with $1 of the following clinical fea-
ease is fluctuating and fatigable underrecognized and misdiagnosed,
tures: unilateral or bilateral fluctuating
with pediatric patients often being
skeletal muscle weakness, which ptosis, unilateral or bilateral fluctuat-
improves with rest. Clinical features symptomatic for years before the di-
ing extraocular muscle weakness, and/
may include predominantly ocular symp- agnosis is made. A strong index of sus-
or skeletal muscle weakness or fatigue
picion is needed for appropriate
toms with ptosis, ophthalmoplegia, and/ and any of the following supportive
investigation and prompt diagnosis, as
or diplopia; bulbar symptoms with dys- tests: Tensilon test or other acetylcho-
there are effective treatments for the
phagia and/or dysphonia; and/or gen- linesterase inhibitor administration
autoimmune form and some CMS. There
eralized symptoms with exercise demonstrating reversal of weakness,
is limited information on the incidence
intolerance and weakness. If left un- elevated AChR or MuSK antibody levels,
and clinical features of pediatric myas-
treated, JMG may progress to re- abnormal nerve conduction studies
thenia in the Canadian population and,
spiratory distress and subsequent demonstrating defect in neuromuscular
hence,theobjectivesofthis studywereto
respiratory failure. Affected children are junction transmission, or abnormal
(1) determine the incidence of JMG and
also at an increased risk for other au- single-fiber electromyography. Exclu-
(2) characterize the clinical features,
toimmune diseases, such as rheumatoid sion criteria included underlying pri-
diagnostic, and treatment trends of pe-
arthritis, juvenile diabetes mellitus, mary muscle, nerve, or metabolic
diatric myasthenia gravis in Canada.
asthma, thyroid disease, and chronic diseases. Cases of transient neonatal
inflammatory demyelinating polyneuro- myasthenia were excluded as they were
pathy.4,5 Transient neonatal myasthenia METHODS beyond the scope of this study.
gravis refers to the self-limited condition Cases of pediatric myasthenia were
caused by the transfer of maternal AChR reported to the Canadian Pediatric RESULTS
antibodies across the placenta. Affected Surveillance Program (CPSP) from Over the 2-year study period, 64 sus-
infants may exhibit ptosis, facial weak- January 1, 2010, through December 31, pected cases of pediatric myasthenia
ness, a weak cry, feeding difficulty, gen- 2011. The CPSP is a national active sur- were reported to the CPSP, of which 57
eralized weakness, hypotonia, and/or veillance program using a voluntary were confirmed as per the study case
respiratory insufficiency. Treatment is 2-tiered reporting process that tracks definition. Reports were received from
largely supportive, with resolution typi- avarietyof pediatric illnesses. More than Alberta, Manitoba, Ontario, Quebec, and
cally within a few weeks.6 2500 practicing Canadian pediatricians Newfoundland. The remaining 7 were

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 ARTICLE

excluded for the following reasons: du- TABLE 1 Clinical Features of Generalized and Ocular JMG
plicate reporting (4 cases), insufficient Characteristics Generalized JMG Ocular JMG
information to confirm a case diagnosis n = 34 (%) n = 18 (%)

(2 cases), and an alternate diagnosis Gender

Male 16 (47) 5 (28)
(1 case). There were 34 cases of gener- Female 18 (53) 13 (72)
alized JMG, 18 cases of exclusively ocular Age of onset, y
JMG, and 5 cases of CMS. The 5 cases of ,3 8 (23) 8 (44)
3–6 2 (6) 5 (28)
CMS included 1 genetically confirmed .6–9 4 (12) 4 (22)
case of choline acetyltransferase de- .9–12 7 (21) 1 (6)
ficiency, 1 slow-channel CMS, 1 Rapsyn .12 10 (29) 0 (0)
Unknown 3 (9) 0 (0)
mutation, and 2 of unknown subtype.
Ethnicity
The clinical characteristics of the 52 Asian 2 (6) 8 (44)
cases of JMG are presented in Table 1. Of African American 4 (12) 3 (16)
White 20 (59) 5 (28)
these, 20 were newly diagnosed cases in East Indian 1 (3) 0 (0)
the 2-year study period, including 14 in- Native American 2 (6) 1 (6)
cident cases in 2010 (10 generalized and Middle Eastern 2 (6) 1 (6)
Multiethnicity 1 (3) 0 (0)
4 ocular) and 6 in 2011 (3 generalized Unknown 2 (6) 0 (0)
and 3 ocular). Reported age of symptom Associated illness
onset for JMG ranged from “birth” to 17 Graves disease 1 (3) 1(6)
Presenting symptom
years (median 10 years) for the gener- Diplopia 19 (56) 8 (44)
alized form compared with 18 months to Ptosis 28 (82) 18 (100)
11 years (median 3½ years) for the oc- Swallowing/chewing difficulty 22 (65) 0 (%)
Hypotonia 12 (35) 0 (0)
ular type. The ratio of girls to boys was Fatigue 21 (62) 0 (0)
1.1:1 in the generalized group and 2.6:1 in Respiratory difficulty 6 (18) 0 (0)
the younger ocular group. Children in the Delayed development 3 (9) 0 (0)
Anxiety/depression 2 (6) 0 (0)
generalized group were predominantly Physical examination findings
white (59%) compared with the ocular Unilateral ptosis 7 (21) 8 (44)
group, which was predominantly Asian Bilateral ptosis 26 (76) 10 (56)
Extraocular abnormalities 20 (59) 9 (50)
(44%). Two antibody-positive patients Facial weakness 19 (56) 0 (0)
also had a diagnosis of Graves disease Hypophonia/voice alteration 14 (41) 0 (0)
(1 generalized case and 1 ocular case). Articulation difficulties 14 (41) 0 (0)
Neck flexor weakness 18 (53) 0 (0)
Another patient with generalized JMG Shoulder girdle weakness 22 (65) 0 (0)
had elevated antimicrosomal antibodies. Hip weakness 24 (71) 0 (0)
Two patients (1 generalized and 1 ocular) Respiratory distress 6 (18) 0 (0)
Respiratory failure 2 (6) 0 (0)
had a family history of thyroid disease.
Ptosis was the most common symptom
reported among both the patients with
generalized and with ocular JMG (82% As shown in Table 2, 97% of patients formed in 76% of generalized cases
and 100%, respectively). Among the pa- with generalized JMG and 100% of and 39% of ocular JMG cases, with
tients with generalized JMG, swallowing/ patients with ocular JMG were tested abnormal results found in 65% and
chewing difficulty (65%) and fatigue for AChR antibodies, and positive titers 43%, respectively.
(62%) were the next most commonly were found in only 67% and 44%, re- Comparison of features of prepubertal
reported symptoms. In regard to physi- spectively. Twelve patients with JMG (10 JMG (age ,12 years at symptom onset;
cal examination, bilateral ptosis was the generalized and 2 ocular) were tested 40 patients) and pubertal/postpubertal
most common physical finding in both for MuSK antibodies; all were negative. JMG (age $12 years at symptom onset;
the patients with generalized (76%) and The Tensilon test was performed in 12 patients) are described in Table 3.
ocular (56%) JMG. Among the patients 47% of generalized cases and in 39% of The prepubertal group demonstrates
with generalized JMG, 18% presented ocular cases and results were abnor- an almost 50/50 split between gener-
with respiratory distress and 6% in re- mal in 88% and 100%, respectively. alized and ocular presentation and
spiratory failure. Nerve conduction studies were per- a 1.4:1 female-to-male ratio compared

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TABLE 2 Diagnostic Tests and Treatment of Generalized and Ocular JMG ies focused on the incidence of pedi-
Generalized JMG n = 34 (%) Ocular JMG n = 18 (%) atric myasthenia gravis but rather all
Performed Percent Abnormal Performed Percent Abnormal ages with subsequent division into age
Diagnostic test
groups. A study conducted in Croatia
AChR antibody 33 (97) 67 18 (100) 44 from 1976 to 1996 found the incidence
MuSK antibody 10 (29) 0 2 (11) 0 of myasthenia gravis among patients
Tensilon test 16 (47) 88 7 (39) 100
Nerve conduction study 26 (76) 65 7 (39) 43
aged 0 to 19 years to be 1.4 per 1 mil-
Electromyography 4 (12) 75 2 (11) 50 lion per year based on retrospective
Short-term treatment Administered Percent Response Administered Percent Response review of database records looking for
Pyridostigmine 33 (97) 100 17 (94) 88
Steroid 18 (53) 94 10 (56) 100
typical history with appropriate clini-
IVIg 21 (62) 81 2 (11) 50 cal features, improvement with anti-
cholinesterase drugs, reduction in
muscle amplitude on repetitive nerve
with the pubertal/postpubertal group, reported to help 1 of the 2 patients who stimulation and detection of AChR
which has 100% generalized pre- received it. antibodies.10 A similar estimate for
sentation and a 2:1 female-to-male patients aged 0 to 19 years of 2.2 per 1
ratio. Among the patients with gener- DISCUSSION million per year with 95% confidence
alized JMG who were tested for AChR The national minimum incidence of JMG limits of 1.4 and 3.4 was obtained in
antibodies, there was higher percent- is 2.0 and 0.9 new cases per 1 million Tanzania, Africa, based on prospective
age of seropositivity in the pubertal/ children per year in 2010 and 2011, study from 1988 to 1998 looking at
postpubertal group (92% vs 52%). respectively, based on estimates of the clinical diagnosis based on positive
However, there is a higher percentage total Canadian pediatric population (0 fatigue test or Tensilon test.11
of short-term remission in the pre- to 17 years old) as reported by CANSIM In this cohort, physicians established
pubertal group (63% vs 25%). from Statistics Canada.8 The only other a diagnosis of pediatric myasthenia
Treatment information (Table 2) was study to report the incidence of myas- based on clinical features and sup-
available for 33 of 34 patients with thenia gravis in a North American portive testing including the presence
generalized JMG. All were started on population was Phillips et al, which of antibodies, Tensilon test or robust
pyridostigmine and all demonstrated reported a total population incidence response to acetylcholinesterase in-
improvement. Of the 18 patients who for all ages (pediatric and adult) of 9.1 hibitor administration, and/or abnor-
received steroids, improvement was per 1 million total population.2 Among mal electrodiagnostic studies. AChR
cited in 94%. Of the 21 patients admin- the patients presented by Phillips et al, antibody testing is often the first in-
istered intravenous immunoglobulin 4.2% were between 0 and 9 years of age vestigation pursued, as it is widely
(IVIg), there was reported improvement at presentation and 9.5% were be- available to pediatricians and pediatric
in 81%. For patients with exclusively tween 9 and 19 years of age at pre- specialists. While AChR antibodies are
ocular presentations, 17 of 18 patients sentation.2 The majority of previous found in 80% of adults with myasthenia
had therapies listed. All were started on studies describing the incidence of gravis,12 numerous studies including
pyridostigmine; improvement occurred myasthenia gravis relied on retro- this current study have demonstrated
in 88% patients. All 10 patients started spective chart reviews from European a high percentage of seronegativity
on prednisone improved. IVIg was countries.9 None of the previous stud- among pediatric myasthenia patients,
especially in prepubertal patients or
those with isolated ocular JMG.13–19 If
TABLE 3 Comparison of Prepubertal and Pubertal/Postpubertal Features of JMG
a child is negative for AChR antibodies
Prepubertal Symptom Pubertal/Postpubertal Symptom
Onset of JMG n = 40 (%) Onset of JMG n = 12 (%) and has a history of early onset of
Type of JMG
symptoms, the possibility of CMS
Generalized 22 (55) 12 (100) should be raised.13,18 Between 40% and
Ocular 18 (45) 0 (0) 50% of adult patients who are negative
Gender
for AChR are found to have antibodies
Male 17 (43) 4 (33)
Female 23 (57) 8 (67) against MuSK.20 MuSK-positive myas-
AChR-positive titers in generalized JMG 11/21 (52) 11 (92) thenia gravis appears to be a distinct
Short-term remission 25 (63) 3 (25)
subtype of myasthenia gravis, which is

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 ARTICLE

more common in female patients and likely reflect differences in the ethnic pediatric myasthenia is based on a
has a more severe disease course with backgrounds and associated genetic survey given to pediatricians and pe-
prominent bulbar and respiratory susceptibility between the populations. diatric subspecialists, including neu-
muscle involvement. MuSK-positive my- HLA antigen plays a key role in several rologists. Consequently, patients who
asthenia gravis is very rare in children.21 autoimmune diseases and has been are followed by family physicians or
All of the 12 children in this cohort associated with myasthenia gravis. For adult neurologists could be missed.
tested for MuSK antibodies were nega- example, HLA-DR3 and -B8 are associ- Additionally, despite the survey being
tive. Additional diagnostic testing, in- ated with 60% of white adult myasthenia nationally administered, responses
cluding Tensilon and electrodiagnostic gravis patients.19,28 Given the higher were received from only 5 of 10 prov-
testing, may be complicated in pediatric incidence of other autoimmune dis- inces and none of the 3 territories.
patients. This is partly due to patient eases in individuals with myasthenia However, the provinces that responded
tolerability and compliance with testing, gravis, especially those that are se- are among the most highly populated,
sometimes requiring sedation for elec- ropositive for AChR,29 it is prudent to representing 78% of the total Canadian
trodiagnostic testing. Also, it is limited perform basic screening especially population based on estimates of
by availability of specialists to perform for diabetes and thyroid disease; we population per year (2010 and 2011) per
the tests. For example, Tensilon testing reported 2 patients with a concurrent province as reported by CANSIM from
requires adjusted dosing, cardiorespi- diagnosis of Graves disease and 2 Statistics Canada.31 Though mecha-
ratory monitoring, and extra caution if patients with family history of thyroid nisms are in place to improve the level
there is any suspicion of CMS (eg, AChR disease. of reporting, such as reminders to
slow channel mutation or COLQ muta- physicians, it nonetheless requires
Prepubertal patients had distinctive
tion) as such patients may clinically physicians to voluntarily participate. In
clinical features compared with the
worsen with exposure to acetylcholin- addition, the reporting system relies
pubertal/postpubertal group, who share
esterase inhibitors.18 on the primary care physician to ac-
more features with adult-onset myas-
curately report all the pertinent data,
The clinical features of JMG in the cur- theniagravis.Asreportedintheliterature,
as it is not possible for the study group
rent study revealed a predominance of the prepubertal patients were more likely
to review each patient chart to confirm
generalized (65%) compared with ex- to present with isolated ocular symptoms
the data. It is clear, however, that the
clusively ocular (35%) JMG. Of those with compared with the overwhelming gen-
diagnosis in reported cases would be
generalized presentation, there was eralized presentation among pubertal/
accurate as part of the inclusion defi-
a subtle female predominance, olderage postpubertal patients.14,16,17 An em-
nition required positive supportive
of onset (median 10 years), and pre- erging female preponderance in the
testing. This included a convincing
dominantly white ethnicity (59%). The pubertal/postpubertal group (female-to-
positive therapeutic response to ace-
ocular patients had a more pronounced male ratio 2:1) compared with the
tylcholinesterase inhibitors, which
female predominance, younger age of prepubertal group (ratio 1.4:1) was
would capture a small but documented
onset (median 3½ years), and pre- noted. Among patients with generalized subset of children who have negative
dominantly Asian ethnicity (44%). The JMG tested for AChR antibodies, 92% supportive testing by antibodies and
female predominance and younger age of the pubertal/postpubertal patients electrodiagnostic studies but have an
of onset of ocular JMG are in keeping were positive compared with 52% of appropriate clinical history and
with the results reported by Sri- the prepubertal group, in keeping with respond to treatment with pyridostig-
udomkajorn et al in Thailand. Their reports of 50% to 71% seropositivity mine.19 Given the survey design, long-
patients presented mainly with ocular among prepubertal patients, 68% to term follow-up of treatment outcome
symptoms (84.3%) at a mean age of 4.1 92% seropositivity among pubertal and disease progression was not avail-
years.22 Compared with studies de- patients, and 80% to 90% seropositivity able and both warrant investigation in
scribing pediatric myasthenia from among postpubertal/adult patients.14,17,30 the future.
China, Korea, Jamaica, Europe, and In- As well, the prepubertal group showed
dia,23–27 whose populations are more a higher rate of short-term remission
ethically uniform, the current study is compared with the pubertal/postpubertal CONCLUSIONS
unique in that the Canadian population group, in keeping with reports by This study represents the largest
is ethnically diverse. Consequently, the Andrews et al14 and Evoli et al.30 exclusively pediatric descriptiveseriesin
differences in terms of gender, age of This study has a number of limitations. North America and the first population-
onset, and subtype of myasthenia gravis The estimated minimum incidence of based study to systematically evaluate

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incidence of pediatric myasthenia gravis thenia gravis in the different patient respond to standard therapies in the
across Canada. The CPSP study results groups. A high index of suspicion is im- short term, including pyridostigmine,
validate data currently reported in the portant for this treatable disease as prednisone, and IVIg.
literature. Given Canada’s ethnic di- a significant percentage of patients, es-
versity, physicians will see patients from pecially in the exclusively ocular sub- ACKNOWLEDGMENTS
a variety of ethnic backgrounds with type, demonstrated negative titers of The authors wish to thank all the physi-
varying genetic susceptibilities and AChR antibodies, which is often the first cians who reported patients to the CPSP
consequently see differences in terms of and may be the only diagnostic test as well as Bobby and Tara Disenhouse
gender, age of onset, and type of myas- pursued. Pediatric patients generally for their support of this project.

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 Clinical Characteristics of Pediatric Myasthenia: A Surveillance Study
Juliana VanderPluym, Jiri Vajsar, Francois Dominique Jacob, Jean K. Mah, Danielle
Grenier and Hanna Kolski
Pediatrics 2013;132;e939
DOI: 10.1542/peds.2013-0814 originally published online September 9, 2013;

Updated Information & including high resolution figures, can be found at:
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
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Downloaded from http://pediatrics.aappublications.org/ by guest on December 25, 2017

 Clinical Characteristics of Pediatric Myasthenia: A Surveillance Study
Juliana VanderPluym, Jiri Vajsar, Francois Dominique Jacob, Jean K. Mah, Danielle
Grenier and Hanna Kolski
Pediatrics 2013;132;e939
DOI: 10.1542/peds.2013-0814 originally published online September 9, 2013;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/132/4/e939

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .

Downloaded from http://pediatrics.aappublications.org/ by guest on December 25, 2017