Aspects of Neuroscience

BCHE4040/LSCI5440

Myasthenia gravis
(MG)
Prof Kwok Fai LAU
School of Life Sciences
2023-24
CUHK 1
Discovery of Myasthenia Gravis (MG)
• First described by the British doctor Thomas Willis in
1685
Willis’s description for a woman

“She speaks freely and readily enough for a while, but

after a long period of speech … she is not able to speak
……. Her voice does not return for one or two hours”
Willis, T. in De Anima Brutorum 404 –407 (Oxonii Theatro Sheldoniano, Oxford, 1672).

• Prevalence = 1 in every 200,000; nearly one million

MG patients worldwide
• MG interferes the transmission between motor neurons
and skeletal muscle
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Hallmarks of MG
(1) Weakening of muscle
• One early sign is eyelid drooping

Drooping of the upper eyelid is common in patients with myasthenia gravis (MG).
Gihus et al. (2010) Myasthenia gravis. Nature Reviews Disease Primers volume 5, Article number: 30 (2019)

• Affect the muscles in controlling eye and eyelid

movement, facial expressions, chewing, talking, and
swallowing
• Weakening of some muscles can be life-threatening
e.g. muscle for chewing and swallowing → choking
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(2) Reduced muscle action potential

Electromyographs show muscle action Distribution of MEPP amplitudes

potential by stimulating motor nerve

(3) Reduced miniature end plate potentials (MEPPs)

MEPP → the small depolarisation of the postsynaptic terminal of
neuromuscular junction generated by the spontaneous
release of acetylcholine to synaptic cleft

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 Acetylcholine receptor and MG
The underlying cause of the disease was
discovered by Jim Patrick and Jon
Lindstrom (1973) when they were raising
antibodies to AChR
Electromyograph

Control rabbit
Immunized rabbit
Action potential (mV)

Immunized rabbit

Control rabbit + Immunized rabbit after

acetylcholinesterase acetylcholinesterase
inhibitor inhibitor treatment
Immunized rabbit +
acetylcholinesterase
inhibitor

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Patrick J and Lindstrom J (1973) Autoimmune response to acetylcholine receptor. Science. 180, 871-2
 Agar gel immunodiffusion assays
Immunized
Rabbit Purified
serum AchR

Rabbit sera in the circular wells

Precipitin Purified
line AchR

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Conclusion: Auto-antibodies against AchR is a cause of paralysis and
muscle weakness in the immunized rabbits

Pre-synaptic neuron

Acetylcholine
Y
Y = Acetylcholine
receptor receptor antibody

Post-synaptic muscle cells 7

1. The blood of MG patients contains antibodies against
AChRs

Lindstrom, J. M., Seybold, M. E., Lennon, V. A., Whittingham, S. & Duane, D. D. (1976) Antibody to acetylcholine receptor in myasthenia gravis. Prevalence, clinical
correlates and diagnostic value. Neurology26, 1054–1059.

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2. Antibodies are present at neuromuscular junctions

Antibody IgG

Protein-A

Enzyme

Substrate Colour
Product
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 3. Injecting the serum from MG patients into mice
produces MG effects

Mouse injected with normal human serum

Mean MEPP = 0.78mV

Mouse injected with MG patient’s serum

Mean MEPP = 0.15mV

0-2 2-4 4-6 6-8 8-10 10-12 12-14 14-16 16-18 18-20

MEPP (x 10-1 mV)

Toyka, K. V., Drachman, D. B., Pestronk, A. & Kao, I. (1975) Myasthenia gravis: passive transfer from man to mouse. Science 190 , 397–399. 10
 4. Removal of antibodies by plasma exchange improves
the muscle weakness
Plasma exchange - a clinical procedure
for the removal of plasma.
Blood cells return
Plasma to patient

Vital capacity (litres)

separator

Substitution
fluid

Arm outstretched
Waste

Vital capacity - the greatest volume of air that

can be expelled from the lungs after taking the
deepest possible breath.

Arm outstretched -

Pinching, A., Peters, D. & Newsom-Davis, J. Remission of myasthenia gravis following plasma exchange. Lancet 2, 1373 –1376 (1976). 11
5. Treatment with acetylcholinesterase inhibitors improve
MG muscle weakness

Electromyographs show muscle responses by stimulating motor nerve

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Summary of clinical features/findings of MG
• The blood of MG patients contains antibodies against AChRs
• Antibodies are present at neuromuscular junctions
• Injecting the serum from MG patients into mice produces MG
effects
• Removal of antibodies by plasma exchange improves MG muscle
weakness
• Treatment with acetylcholinesterase inhibitors improves MG
muscle weakness
Conclusion: Auto-antibodies that block/damage acetylcholine
receptors at the postsynaptic neuromuscular junction is a cause
of MG

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Muscle specific tyrosine kinase (MuSK) antibodies
• MuSK is a receptor tyrosine kinase required for the formation
and maintenance of the neuromuscular junction.

Staining of cell expressing MuSK by using

(1) Plasma from MG patient (2) Plasma from

without AChR Ab Healthy control

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 Low density lipoprotein receptor-related protein 4
(LRP4) antibodies
• LRP4 is a receptor for agrin
• Agrin is essential for the development of neuromuscular junction

Control serum Serum from a patient

Staining of cells transfected with huLRP4 (

tagged with EGFP) by double-seronegative
(both AChR- and MuSK Ab) antisera from MG
patients (Red channel).
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Pevzner A et al (2012) Anti-LRP4 autoantibodies in AChR- and MuSK-antibody-negative myasthenia gravis. J Neurol. 259(3):427-35.
 Roles of MuSK and LRP4 in developing NMJ
• Agrin–LRP4–MuSK signaling pathway to induce AChR clustering

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Lucia S. Borges and David P. Richman 2020

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1. Motor neurons secrete agrin 5. clustering of acetylcholine receptors

2. Agrin binds to LRP4 on the muscle cell
3. Agrin/LRP4 complex binds to MuSK
→ activation of MuSK
4. Activated MuSK phosphorylates
downstream signaling components
6. Acetylcholine (ACh), secreted by motor
neurons, binds to the clustered AChRs
and initiates muscle contraction
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Ryanodine receptors (RyR) antibody
• RyR is intracellular calcium channels for releasing calcium ions
from ER to cytoplasm in muscle cells
• Calcium is essential for muscle Voltage-gated
calcium channel
contraction

http://watcut.uwaterloo.ca/webnotes/Pharmacology/CellExcitation.html

Purified RyR

Mygland A et al. Ryanodine receptor autoantibodies in myasthenia 17

gravis patients with a thymoma. Ann Neurol. 1992 Oct;32(4):589-91.
Titin antibodies
Muscle fiber
• Titin is a giant protein abundantly
expressed in muscle which
participates in muscle contraction

Titin

Lane 2-4, Sera from patients with MG and thymoma (MGT)

Lane 5-6, Sera from MG patients without thymoma
Lane 7, Serum from an amyotrophic lateral sclerosis (= Motor neuron
disease) patient
Lane 8, healthy individual serum
Lane 9, antibody from control
Lane 10, staining with antibody affinity-purified from an MGT serum
Lane 11, Antibody against titin
Aarli JA et al. Patients with myasthenia gravis and thymoma have in their sera IgG autoantibodies against Lane 12, an anti-myosin monoclonal antibody. 18
titin. Clin Exp Immunol. 1990 Nov;82(2):284-8.6
Kv1.4 antibodies
• Kv 1.4 is a subunit of a voltage-gated K+ channel in muscle cells

Kv1.4 transfected cells double staining

S. Suzuki et al (2005) Novel autoantibodies to a voltage-gated potassium channel K V1.4 in a severe form
of myasthenia gravis. Journal of Neuroimmunology. vol. 170, no.1-2, pp. 141–149.

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Gihus et al. (2010) Myasthenia gravis. Nature Reviews Disease Primers volume 5, Article number: 30 (2019)

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There is no cure for MG
Treatment for MG
• Acetylcholinesterase inhibitors
→ stops degradation of acetylcholine
→ Increase concentration of acetylcholine
• Immunosuppressive drugs → reduce production of auto-
antibodies

• Surgical removal of the thymus gland→ reduces helper T cells

production
→ Thymus → Helper T cells production
→ Helper T cells promote B cells to make antibody
• Plasma exchange → remove of the abnormal antibodies from
the plasma of the blood.
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