Meet the editors

Prof. Isam Jaber Al-Zwaini was born on January 4, 1963, in Baghdad, Iraq. After graduating from Al-Mustansiryia College of Medicine in 1987, he worked as a house officer in different hospitals in Baghdad for 15 months, followed by military services for 3 years. He started his pediatric studies in 1991 and gained Fellowship of the Iraqi Commission for Medical Specializations in 1996. He worked as a lecturer in the Department of Pediatrics,

Al-Anbar Medical College, from 1996 to 2001, where he was upgraded to assistant professor in 2008. In 2007, he gained associate membership of the Royal College of Paediatrics and Child Health, UK. He has been the head of the Pediatric Department in Al-Anbar and Al-Kindy Medical College for many years. He has published more than 30 scientific papers in different pediatric fields, and his special interests are pediatric hematology, neurology, and nutrition.

Assistant Professor Ali AL-Mayahi was born in Baghdad on September 11, 1968. He graduated from Al-Mustanisryia College of Medicine in 1992 and worked as a house officer for 2 years in Baghdad hospitals, before starting his pediatric specialty in 1994. He subsequently gained the degree of Fellowship of Iraqi Medical Specialization in 1999 and the Arab Board in Pediatrics in 2000. He then worked as a pediatric specialist at Kirkuk Welfare Hospi-

tal for Children and at Al-Elwyia Pediatric Teaching Hospital. Professor Al-Mayahi joined Al-Kindy College of Medicine, University of Baghdad, as a lecturer in 2006 and became an assistant professor in 2012. He was the head of the Pediatric Department at Al-Kindy College of Medicine from 2016 to 2018. His interests are neonatology, neurology, and hematology.

Contents

**Section 1**

**Section 2**

*by Adel A. Kareem*

Myasthenia Gravis

**Section 3**

Gravis

*by Valerii Voinov*

Anticholinesterases

**Preface III**

Introduction **1**

**Chapter 1 3**

Pediatric Myasthenia Gravis **13**

**Chapter 2 15**

**Chapter 3 27**

Myasthenia Gravis - Therapeutic Aspects **37**

**Chapter 4 39**

**Chapter 5 57**

**Chapter 6 69**

Structure-Based Approaches to Antigen-Specific Therapy of Myasthenia

Maternal and Neonatal Outcome of Pregnancies with Autoimmune

*by Miljana Z. Jovandaric and Svetlana J. Milenkovic*

*by Jiang Xu, Kaori Noridomi and Lin Chen*

Plasmapheresis in Treatment of Myasthenia Gravis

*by Zeynep Özdemir and Mehmet Abdullah Alagöz*

Introductory Chapter: Myasthenia Gravis - An Overview

*by Isam Jaber AL-Zwaini and Ali AL-Mayahi*

Myasthenic Syndrome in Children

## Contents


Preface

Myasthenia gravis (MG) is a rare potentially fatal chronic autoimmune disorder. Circulating autoantibodies directed against components of the neuromuscular junction of skeletal muscles, most commonly nicotinic acetylcholine receptor (nAChR) and associated protein in the postsynaptic membrane, block neuromuscular

transmission resulting in muscle weakness. This muscle weakness typically worsens with continued activity, improves on rest, and is of variable severity ranging from mild ocular muscle weakness to severe generalized muscle weakness, involving the respiratory muscle with impending respiratory failure. The content of this short

The first chapter is an Introductory chapter written by the editors, in which we trace the history of MG as a disease entity, which was reported in the Seventeenth century with the death of the Native American Chief Opechancanough in 1664. The chapter throws light on the etiology, epidemiology, pathophysiology, clinical

The second chapter written by Dr. Adel A. Kareem is dedicated to the myasthenic syndrome in children, which has special varieties whereby it may be inherited or acquired as an autoimmune disorder. Autoimmune MG is usually transient and is evident when a baby born to a myasthenic mother is floppy with a weak cry and suffers from ptosis and impaired respiration. Fortunately, most of these cases are transient and complete recovery will take place after a few weeks; however, these individuals need good supportive measures until recovery is ensured. On the other hand, classical autoimmune MG, which is known as juvenile MG, can occur at any childhood age group. An interesting occurrence in childhood myasthenia is congenital myasthenia syndrome, which is not uncommon. This nonimmunologic-mediated heterogeneous group has variable presentation, ranging from mild to severe weakness and respiratory failure.

Dr. Miljana Z. Jovandaric and Svetlana J. Milenkovic in the third chapter discuss the maternal and neonatal outcome of pregnancies with autoimmune MG. Transient neonatal MG is an uncommon type of MG affecting the newborns of mothers who suffer from the disorder or asymptomatic mothers having specific circulating autoantibodies. In most cases, the intensity of transient neonatal MG is not associated with the mothers' condition but rather with maternal antibody titers. The detection of the disease is generally possible several hours after birth. The symptoms of transient neonatal MG include hypotonia, feeding difficulties, weak cry, facial diplegia, and breathing difficulties in the affected newborns. These manifestations gradually disappear as maternally derived antibodies wane. Monitoring of these newborns is necessary for the first seven days after birth since during this period, transient neonatal myasthenic symptoms can be detected, especially on the second day.

The fourth chapter by Dr. Jiang Xu, Kaori Noridomi and Lin Chen reviews the structure-based approaches to antigen-specific therapy of MG. About 85% of cases of MG are caused by pathological autoimmune antibodies to muscle nAChRs. An attractive approach to treating MG is, therefore, blocking the binding of autoimmune antibodies to nAChRs, removing specific nAChR antibodies, or selectively

book is divided into three sections involving six chapters.

presentations, diagnostic tests, and treatment of MG.
