Clinical features

• painless fatigue with exercise

• weakness also precipitated by emotional stress, pregnancy, infection, surgery

• variable distribution of weakness:

o ocular

■ ocular myasthenia only remains in about 10%

o bulbar: weakness of chewing, swallowing, speech, whistling and head lolling o limbs (proximal and distal) o generalised o respiratory: breathlessness, ventilatory failure

Note: The classical MG image is 'the thinker'— the hand used to hold the mouth closed and the head up.

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