Miastenia grave avaliação crítica dos tratamentos

Assis, José Lamartine de

doi:10.1590/S0004-282X1990000100009

Resumos

O autor inicia realçando a dificuldade do tema pois, de um lado, não há certeza acerca do valor dos métodos de tratamento usados em rotina no momento e, de outro, há notória escassez de estudos controlados prospectivos e duplo-cegos. Em grande parte esse dilema decorre da inaplicabilidade, no momento, de métodos específicos de tratamento. A seguir, o autor trata com mais ênfase dos quatro métodos de tratamento mais usados rotineiramente: drogas colinérgicas, timectomia e timomectomia, imunossupressão medicamentosa esteróide e não esteróide e plasmaférese. O tratamento mediante o emprego de anticorpos é referido de modo perfuntório, inclusive a imunoterapia específica experimental com anticorpos e células supressoras. O autor encerra a exposição fazendo avaliação crítica dos métodos de irradiação no tratamento da miastenia grave.

The author emphasizes the difficulty of the subject since on the one hand there is no assurance about the value of the treatment methods performed commonly at the moment, and on the other hand there is an evident lack of prospectively controlled trials and double-blind studies. Mostly this dilemma occurs by the lack at the moment of any specific treatment. The author deals with the four therapeutic methods most commonly used: colinerglc drugs, thymectomy, immunosuppressive drugs and plasmapheresis. At last, the experimental specific immunotherapy by the use of antibodies and suppressive cells and the irradiation methods are discussed.

José Lamartine de Assis

Departamento de Neurologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP): Professor Adjunto. Aula ministrada no Curso Doenças Neuromusculares do 13º Congresso Brasileiro de Neurologia e 13» Reunião da Liga Brasileira de Epilepsia (São Paulo, 24 a 29 de setembro de 1988)

RESUMO

O autor inicia realçando a dificuldade do tema pois, de um lado, não há certeza acerca do valor dos métodos de tratamento usados em rotina no momento e, de outro, há notória escassez de estudos controlados prospectivos e duplo-cegos. Em grande parte esse dilema decorre da inaplicabilidade, no momento, de métodos específicos de tratamento. A seguir, o autor trata com mais ênfase dos quatro métodos de tratamento mais usados rotineiramente: drogas colinérgicas, timectomia e timomectomia, imunossupressão medicamentosa esteróide e não esteróide e plasmaférese. O tratamento mediante o emprego de anticorpos é referido de modo perfuntório, inclusive a imunoterapia específica experimental com anticorpos e células supressoras. O autor encerra a exposição fazendo avaliação crítica dos métodos de irradiação no tratamento da miastenia grave.

SUMMARY

The author emphasizes the difficulty of the subject since on the one hand there is no assurance about the value of the treatment methods performed commonly at the moment, and on the other hand there is an evident lack of prospectively controlled trials and double-blind studies. Mostly this dilemma occurs by the lack at the moment of any specific treatment. The author deals with the four therapeutic methods most commonly used: colinerglc drugs, thymectomy, immunosuppressive drugs and plasmapheresis. At last, the experimental specific immunotherapy by the use of antibodies and suppressive cells and the irradiation methods are discussed.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Clínica Neurológica, FMUSP . Caixa Postal 3461 . 01051 São Paulo SP . Brasil

1. Arsura EL, Bick A, Brunner NG, Namba T, Grob O . High-dose intravenous immunoglobulin in the management of myasthenia gravis. Arch Int Med 146:1365, 1986.
2. Assis JL . Tratamentos dos casos graves de miastenia grave. Ação do ACTH e cortisona: considerações a propósito de três casos. Arq Neuro-Psiquiat (São Paulo) 14:28, 1956.
3. Assis JL . Tratamento das formas severas de miastenia pelo ACTH por via intravenosa. Arq Neuro-Psiquiat (São Paulo) 18:359, 1960.
4. Assis JL, Curi N . Timectomia na miastenia grave: avaliação dos resultados em 73 pacientes. Arq Neuro-Psiquiat (São Paulo) 36:16, 1978.
5. Assis JL, Marchiori PE, Zambon AA, Curi N, Filomeno LTB, Scaff M . Immunosuppression with corticosteroids and thymectomy in myasthenia gravis: an evaluation of immediate and short term results in 20 patients. Arq Neuro-Psiquiat (São Paulo) 43:17, 1985.
6. Assis JL, Marchiori PE, Scaff M, Zambon AA . Tratamento da miastenia grave mediante immunossupressão medicamentosa não esteróide. Arq Neuro-Psiquiat (São Paulo) 44:109, 1986.
7. Assis JL, Marchiori PE, Zambon AA, Scaff M . Tratamento conservador e timectomia na miastenia grave: resultados avaliados a curto c longo prazos. Arq Neuro-Psiquiat (São Paulo) 45:119, 1987.
8. Bolooki H, Schwartzman RJ . Role of steroids in management of patients with myasthenia gravis undergoing thymectomy. J Thorac Cardiovasc Surg 75:754, 1978.
9. Christadoss P . Myasthenia gravis therapy with antibody ro Leu 3/t4 determinant. Ann NY Acad Sci 505:901, 1987.
10. Dau PC, Lindstrom JM, Cassei CK, Clark EC . Plasmapheresis in myasthenia gravis and polymyositis. In Dau PC (ed): Plasmapheresis and the Immunobiology of Myasthenia Gravis. Houghton Mifflin, Boston, 1979, pg 229.
11. d'Empaire G, Goaglin DC, Perlo VP, Pontoppidan H . Effect of prethymectomy plasma exchange on postoperative respiratory function in myasthenia gravis. J Thorac Cardiovasc Surg 89:592, 1985.
12. Drachman BD . Present and future treatment of myasthenia gravis. N Engl J Med 316:743, 1987.
13. Engel WK, Lichter AS, Dalakas MC . Splenic and total-body irradiation treatment of myasthenia gravis. Ann NY Acad Sci 377:744, 1981.
14. Engel AG, Lambert EH, Santa T . Study of long-term anticholinesterase therapy. Neurology 23:1273, 1973.
15. Gajdos H, Outin D, Morel E, Raphael JC, Goulon M . High-dose intravenous gammaglobulin for myasthenia gravis: an alternative to plasma exchange? Ann NY Acad Sci 505:842. 1987.
16. Genkins G, Papatestas AE, Kornfeld P, Horowitz SH . Studies in myasthenia gravis: staging and gammaglobulin. In Dau PC (ed): Plasmapheresis and the Immunobiology of Myasthenia Gravis. Houghton Mifflin, Boston, 1979, pg 144.
17. Goldman AJ, Herrman C Jr., Keesey JC, Mulder DG, Brown WJ . Myasthhenia gravis and invasive thymoma: a 20 years experience. Neurology 25:1021, 1975.
18. Grob D, Brunner NG, Namba T . The natural course of myasthenia gravis and the effect of various therapeutic measures. Ann NY Acad Sci 377:652, 1981.
19. Hoffmann WE, Reuther P, Schalke B, Martens HG . Splenectomy in myasthenia gravis: a therapeutic concept? J Neurol 232:215, 1985.
20. Howard FM, Duane DD, Lambert EH . Alternate-day prednisone: preliminary report of a double-blind controlled study. Ann NY Acad Sci 574:596, 1976.
20a. Iivanainen M, Taskinen E, Kovanen J . Frequency of cerebrospinal fluid pleocytosis in multiple sclerosis detected by combined millipore filtration and cytocentrifuge technique. Neurology 29:538, 1979.
21. Jaretaki A . Symposium on therapeutic controversies: myasthenai gravis. Cervical Thymectomy (con) 102:288, 1978.
22. Johns TR . Steroids and immunosuppressive drugs. Trans Am Neurol Assoc 103:278, 1978.
23. Johns TR . Long-term corticosteroid treatment of myasthenia gravis. Ann NY Acad Sci 500:568, 1987.
24. Joseph BS, Johns TR . Recurrence of nonneoplastic thymus after thymectomy for myasthenia gravis. Neurology 23:109, 1973.
25. Kornfeld P, Genkins G, Papatestas AE, Horowitz SH . Steroid therapy in myasthenia gravis associated with thymoma. Mt Sinai J Med 45:106, 1978.
26. Mann JD, Johns TR, Campa JF, Muller WH . Long-term prednisone followed by thymectomy in myasthenia gravis. Ann NY Acad Sci 274:608, 1976.
27. Marchiori PE . Identificação e significado de elementos imunológicos e morfológicos na miastenia grave: Valor diagnóstico para o timoma. Tese (Livre-Docência). Faculdade de Medicina, Universidade de São Paulo. São Paulo, 1987.
27a. Marchiori PE, Scaff M, Assis JL . Failure of cyclosporin-A in myasthenia gravis. Arq Neuro-Psiquiat (São Paulo) 47:91, 1989.
27b. Marchiori PE, Cossermelli W, Weltman E, Scaff M, Assis JL . Unremission from polymyositis and myasthenia gravis after total body irradiation. Neurobiologia (Recife) 51:157, 1988.
28. Massaoka A, Monden Y . Comparison of the results of transesternal simple, transcervical simple, and extended thymectomy. Ann NY Acad Sci 377:755, 1981.
29. Matell G . Immunosuppressive drugs: azathioprine in the treatment of myasthenia gravis. Ann NY Acad Sci 500:588, 1987.
30. Mcintosh KR, Drachman DB . Properties of suppressor cells-induced to acetylcholine receptor using cyclosporin A. Ann NY Acad Sci 500:628, 1987.
31. Mcintosh KR, Drachman DB . Induction of suppressor cells specific for ACHR in experimental autoimmune myasthenia gravis. Science 232:401, 1986.
32. McGuillen MP, Leone MG . A treatment carol: thymectomy revisited. Neurology 27:1103, 1977.
33. McGuillen MP . Symposium on therapeutic controversies. Thymectomy (con). Trans Am Neurol Assoc 103:283, 1978.
34. Mertens HG, Hertel G, Reuther P, Ricker K . Effect of immunosuppressive drugs (azathioprine). Ann NY Acad Sci 377:691, 1981.
35. Mulder DG, Herrman C Jr, Buckberg GD . Effect of thymectomy in patients with myasthenia gravis. Am J Surg 128:202, 1974.
36. Newsom-Davis J, Ward CD, Wilson SG, Pinching AJ, Vincent A . Plasmapheresis: short and long-term benefits? In Dau PC (ed): Plasmapheresis and the Immunobiology on Myasthenia Gravis. Houghton Mifflin, Boston, 1979, pg 199.
37. Olanov CW, Wechsler AS, Sirotkin-Roses M, Stojich J, Roses AD . Thymectomy as primary therapy in myasthenia gravis. Ann NY Acad Sci 505:595, 1987.
38. Oosterhuis HJGH . Studies in myasthenia gravis. J Neurol Sci 1:512, 1964.
39. Oosterhuis HJGH . Myasthenia Gravis. Churchill Livingstone, New York, 1984.
40. Papatestas A, Genkins G . Cervical thymectomy. Trans Am Neurol Assoc 103:286, 1978.
41. Perlo VP, Poskanzor DC, Schwab RS, Viets HR, Osserman KE, Genkins G . Myasthenia gravis: evaluation of treatment in 1355 patients. Neurology 16:431, 1966.
42. Pirofsky B, Reid RH, Bardana EJ, Baker RL . Myasthenia gravis treated with purified anti-thymocyte anti-serum. Neurology 29:112, 1979.
43. Pirofsky B . The effect of anti-thymocyte. anti-serum in progressive myasthenia gravis. Ann NY Acad Sci 377:779, 1981.
44. Richman DP . Treatment of myasthenia gravis, J Neurol 232:202, 1985.
45. Rowland LP . Controversies about the treatment of myasthenia gravis. J Neurol Neurosurg Psychiat 43:644, 1980.
46. Rowland LP . General discussion on therapy in myasthenia gravis. Ann NY Acad Sci 500:607, 1987.
46a. Sanders DB, Howard JF, Johns TR, Campa JF . High dose daily prednisone in the treatment of myasthenia gravis. In Dau P (ed): Plasmapheresis and the immunobiology of myasthenia gravis. Houghton Mifflin, Boston, 1979, pg 289.
47. Schulz MD, Schwab RS . Results of thymic (mediastinal) irradiation in patients with myasthenia gravis. Ann NY Acad Sci 183:303, 1971.
48. Schwartz MS, Sargeant MX, Swash M . Neostigmine-induced end-plate proliferation in the rat: a study using supra-vital methylene blue. Neurology 27:289, 1977.
48a. Sghirlanzoni A, Peluchetti D, Mantegazza R, Fiacchino F, Cornelio F . Myasthenia gravis: prolonged treatment with steroids. Neurology 34:170, 1984.
49. Shindler E (ed) . Cyclosporin in Autoimmune Diseases. Springer, Berlin, 1985.
50. Simpson JA . An evaluation of thymectomy in myasthenia gravis. Brain 81:112. 1958.
51. Slater G, Papatestas AE, Genkins G, Kornfeld P, Horowitz SH, Bender A . Thymomas in patients with myasthenia gravis. Ann Surg 188:171, 1978.
51a. Somer H, Miiller K, Kinnunen E . Myasthenia gravis associated with multiple sclerosis: epidemiological survey and immunological findings. J Neurol Sci 89:37, 1989.
52. Soroujon MC, Fuchs S . Antiidiotypic antibodies in the regulation of experimental autoimmune myasthenia gravis. Ann NY Acad Sci 505:676, 1987.
53. Tindall RSA, Rollins JA, Phillips TJ, Greekee RG, Wells L, Belendiuk G . Preliminary results of a double-blind randomized, placebo-controlled trial of cyclosporine in myasthenia gravis. N Eugl J Med 316:719, 1987.
54. Uchiyama M, Ichikawa Y, Takaya M, Moriuchi J, Shimizu H, Arimori S . High-dose gammaglobulin therapy of generalized myasthenia gravis. Ann NY Acad Sci 505:868, 1987.
55. Waldor MX, O'Hearn M, Sriram S, Steinman L . Treatment of experimental autoimmune myasthenia gravis with monoclonal antibodies to immune response gene products. Ann NY Acad Sci 505:655, 1987.

Miastenia grave avaliação crítica dos tratamentos

Myasthenia gravis: criticai evaluation of the treatments

Datas de Publicação

Publicação nesta coleção
25 Maio 2011
Data do Fascículo
Mar 1990

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Arsura EL, Bick A, Brunner NG, Namba T, Grob O . High-dose intravenous immunoglobulin in the management of myasthenia gravis. Arch Int Med 146:1365, 1986.

[2] 2. Assis JL . Tratamentos dos casos graves de miastenia grave. Ação do ACTH e cortisona: considerações a propósito de três casos. Arq Neuro-Psiquiat (São Paulo) 14:28, 1956.

[3] 3. Assis JL . Tratamento das formas severas de miastenia pelo ACTH por via intravenosa. Arq Neuro-Psiquiat (São Paulo) 18:359, 1960.

[4] 4. Assis JL, Curi N . Timectomia na miastenia grave: avaliação dos resultados em 73 pacientes. Arq Neuro-Psiquiat (São Paulo) 36:16, 1978.

[5] 5. Assis JL, Marchiori PE, Zambon AA, Curi N, Filomeno LTB, Scaff M . Immunosuppression with corticosteroids and thymectomy in myasthenia gravis: an evaluation of immediate and short term results in 20 patients. Arq Neuro-Psiquiat (São Paulo) 43:17, 1985.

[6] 6. Assis JL, Marchiori PE, Scaff M, Zambon AA . Tratamento da miastenia grave mediante immunossupressão medicamentosa não esteróide. Arq Neuro-Psiquiat (São Paulo) 44:109, 1986.

[7] 7. Assis JL, Marchiori PE, Zambon AA, Scaff M . Tratamento conservador e timectomia na miastenia grave: resultados avaliados a curto c longo prazos. Arq Neuro-Psiquiat (São Paulo) 45:119, 1987.

[8] 8. Bolooki H, Schwartzman RJ . Role of steroids in management of patients with myasthenia gravis undergoing thymectomy. J Thorac Cardiovasc Surg 75:754, 1978.

[9] 9. Christadoss P . Myasthenia gravis therapy with antibody ro Leu 3/t4 determinant. Ann NY Acad Sci 505:901, 1987.

[10] 10. Dau PC, Lindstrom JM, Cassei CK, Clark EC . Plasmapheresis in myasthenia gravis and polymyositis. In Dau PC (ed): Plasmapheresis and the Immunobiology of Myasthenia Gravis. Houghton Mifflin, Boston, 1979, pg 229.

[11] 11. d'Empaire G, Goaglin DC, Perlo VP, Pontoppidan H . Effect of prethymectomy plasma exchange on postoperative respiratory function in myasthenia gravis. J Thorac Cardiovasc Surg 89:592, 1985.

[12] 12. Drachman BD . Present and future treatment of myasthenia gravis. N Engl J Med 316:743, 1987.

[13] 13. Engel WK, Lichter AS, Dalakas MC . Splenic and total-body irradiation treatment of myasthenia gravis. Ann NY Acad Sci 377:744, 1981.

[14] 14. Engel AG, Lambert EH, Santa T . Study of long-term anticholinesterase therapy. Neurology 23:1273, 1973.

[15] 15. Gajdos H, Outin D, Morel E, Raphael JC, Goulon M . High-dose intravenous gammaglobulin for myasthenia gravis: an alternative to plasma exchange? Ann NY Acad Sci 505:842. 1987.

[16] 16. Genkins G, Papatestas AE, Kornfeld P, Horowitz SH . Studies in myasthenia gravis: staging and gammaglobulin. In Dau PC (ed): Plasmapheresis and the Immunobiology of Myasthenia Gravis. Houghton Mifflin, Boston, 1979, pg 144.

[17] 17. Goldman AJ, Herrman C Jr., Keesey JC, Mulder DG, Brown WJ . Myasthhenia gravis and invasive thymoma: a 20 years experience. Neurology 25:1021, 1975.

[18] 18. Grob D, Brunner NG, Namba T . The natural course of myasthenia gravis and the effect of various therapeutic measures. Ann NY Acad Sci 377:652, 1981.

[19] 19. Hoffmann WE, Reuther P, Schalke B, Martens HG . Splenectomy in myasthenia gravis: a therapeutic concept? J Neurol 232:215, 1985.

[20] 20. Howard FM, Duane DD, Lambert EH . Alternate-day prednisone: preliminary report of a double-blind controlled study. Ann NY Acad Sci 574:596, 1976.

[21] 20a. Iivanainen M, Taskinen E, Kovanen J . Frequency of cerebrospinal fluid pleocytosis in multiple sclerosis detected by combined millipore filtration and cytocentrifuge technique. Neurology 29:538, 1979.

[22] 21. Jaretaki A . Symposium on therapeutic controversies: myasthenai gravis. Cervical Thymectomy (con) 102:288, 1978.

[23] 22. Johns TR . Steroids and immunosuppressive drugs. Trans Am Neurol Assoc 103:278, 1978.

[24] 23. Johns TR . Long-term corticosteroid treatment of myasthenia gravis. Ann NY Acad Sci 500:568, 1987.

[25] 24. Joseph BS, Johns TR . Recurrence of nonneoplastic thymus after thymectomy for myasthenia gravis. Neurology 23:109, 1973.

[26] 25. Kornfeld P, Genkins G, Papatestas AE, Horowitz SH . Steroid therapy in myasthenia gravis associated with thymoma. Mt Sinai J Med 45:106, 1978.

[27] 26. Mann JD, Johns TR, Campa JF, Muller WH . Long-term prednisone followed by thymectomy in myasthenia gravis. Ann NY Acad Sci 274:608, 1976.

[28] 27. Marchiori PE . Identificação e significado de elementos imunológicos e morfológicos na miastenia grave: Valor diagnóstico para o timoma. Tese (Livre-Docência). Faculdade de Medicina, Universidade de São Paulo. São Paulo, 1987.

[29] 27a. Marchiori PE, Scaff M, Assis JL . Failure of cyclosporin-A in myasthenia gravis. Arq Neuro-Psiquiat (São Paulo) 47:91, 1989.

[30] 27b. Marchiori PE, Cossermelli W, Weltman E, Scaff M, Assis JL . Unremission from polymyositis and myasthenia gravis after total body irradiation. Neurobiologia (Recife) 51:157, 1988.

[31] 28. Massaoka A, Monden Y . Comparison of the results of transesternal simple, transcervical simple, and extended thymectomy. Ann NY Acad Sci 377:755, 1981.

[32] 29. Matell G . Immunosuppressive drugs: azathioprine in the treatment of myasthenia gravis. Ann NY Acad Sci 500:588, 1987.

[33] 30. Mcintosh KR, Drachman DB . Properties of suppressor cells-induced to acetylcholine receptor using cyclosporin A. Ann NY Acad Sci 500:628, 1987.

[34] 31. Mcintosh KR, Drachman DB . Induction of suppressor cells specific for ACHR in experimental autoimmune myasthenia gravis. Science 232:401, 1986.

[35] 32. McGuillen MP, Leone MG . A treatment carol: thymectomy revisited. Neurology 27:1103, 1977.

[36] 33. McGuillen MP . Symposium on therapeutic controversies. Thymectomy (con). Trans Am Neurol Assoc 103:283, 1978.

[37] 34. Mertens HG, Hertel G, Reuther P, Ricker K . Effect of immunosuppressive drugs (azathioprine). Ann NY Acad Sci 377:691, 1981.

[38] 35. Mulder DG, Herrman C Jr, Buckberg GD . Effect of thymectomy in patients with myasthenia gravis. Am J Surg 128:202, 1974.

[39] 36. Newsom-Davis J, Ward CD, Wilson SG, Pinching AJ, Vincent A . Plasmapheresis: short and long-term benefits? In Dau PC (ed): Plasmapheresis and the Immunobiology on Myasthenia Gravis. Houghton Mifflin, Boston, 1979, pg 199.

[40] 37. Olanov CW, Wechsler AS, Sirotkin-Roses M, Stojich J, Roses AD . Thymectomy as primary therapy in myasthenia gravis. Ann NY Acad Sci 505:595, 1987.

[41] 38. Oosterhuis HJGH . Studies in myasthenia gravis. J Neurol Sci 1:512, 1964.

[42] 39. Oosterhuis HJGH . Myasthenia Gravis. Churchill Livingstone, New York, 1984.

[43] 40. Papatestas A, Genkins G . Cervical thymectomy. Trans Am Neurol Assoc 103:286, 1978.

[44] 41. Perlo VP, Poskanzor DC, Schwab RS, Viets HR, Osserman KE, Genkins G . Myasthenia gravis: evaluation of treatment in 1355 patients. Neurology 16:431, 1966.

[45] 42. Pirofsky B, Reid RH, Bardana EJ, Baker RL . Myasthenia gravis treated with purified anti-thymocyte anti-serum. Neurology 29:112, 1979.

[46] 43. Pirofsky B . The effect of anti-thymocyte. anti-serum in progressive myasthenia gravis. Ann NY Acad Sci 377:779, 1981.

[47] 44. Richman DP . Treatment of myasthenia gravis, J Neurol 232:202, 1985.

[48] 45. Rowland LP . Controversies about the treatment of myasthenia gravis. J Neurol Neurosurg Psychiat 43:644, 1980.

[49] 46. Rowland LP . General discussion on therapy in myasthenia gravis. Ann NY Acad Sci 500:607, 1987.

[50] 46a. Sanders DB, Howard JF, Johns TR, Campa JF . High dose daily prednisone in the treatment of myasthenia gravis. In Dau P (ed): Plasmapheresis and the immunobiology of myasthenia gravis. Houghton Mifflin, Boston, 1979, pg 289.

[51] 47. Schulz MD, Schwab RS . Results of thymic (mediastinal) irradiation in patients with myasthenia gravis. Ann NY Acad Sci 183:303, 1971.

[52] 48. Schwartz MS, Sargeant MX, Swash M . Neostigmine-induced end-plate proliferation in the rat: a study using supra-vital methylene blue. Neurology 27:289, 1977.

[53] 48a. Sghirlanzoni A, Peluchetti D, Mantegazza R, Fiacchino F, Cornelio F . Myasthenia gravis: prolonged treatment with steroids. Neurology 34:170, 1984.

[54] 49. Shindler E (ed) . Cyclosporin in Autoimmune Diseases. Springer, Berlin, 1985.

[55] 50. Simpson JA . An evaluation of thymectomy in myasthenia gravis. Brain 81:112. 1958.

[56] 51. Slater G, Papatestas AE, Genkins G, Kornfeld P, Horowitz SH, Bender A . Thymomas in patients with myasthenia gravis. Ann Surg 188:171, 1978.

[57] 51a. Somer H, Miiller K, Kinnunen E . Myasthenia gravis associated with multiple sclerosis: epidemiological survey and immunological findings. J Neurol Sci 89:37, 1989.

[58] 52. Soroujon MC, Fuchs S . Antiidiotypic antibodies in the regulation of experimental autoimmune myasthenia gravis. Ann NY Acad Sci 505:676, 1987.

[59] 53. Tindall RSA, Rollins JA, Phillips TJ, Greekee RG, Wells L, Belendiuk G . Preliminary results of a double-blind randomized, placebo-controlled trial of cyclosporine in myasthenia gravis. N Eugl J Med 316:719, 1987.

[60] 54. Uchiyama M, Ichikawa Y, Takaya M, Moriuchi J, Shimizu H, Arimori S . High-dose gammaglobulin therapy of generalized myasthenia gravis. Ann NY Acad Sci 505:868, 1987.

[61] 55. Waldor MX, O'Hearn M, Sriram S, Steinman L . Treatment of experimental autoimmune myasthenia gravis with monoclonal antibodies to immune response gene products. Ann NY Acad Sci 505:655, 1987.