Myasthenia Gravis: Autoimmune Triggers, Fatigue, and Acupuncture Relief

Myasthenia Gravis is a chronic autoimmune disease caused by a disorder of acetylcholine transmission at the neuromuscular junction.

The exact etiology remains unclear, and most scholars consider it an autoimmune disease. The majority of patients present with thymic abnormalities, such as thymoma or thymic hyperplasia. The thymus is a vital organ regulating immune function, maintaining immune homeostasis so that the body only mounts immune responses against foreign substances and not against normal self-tissues. Infections, emotional stress, excessive fatigue, trauma, childbirth, and the use of certain medications (such as quinine, quinidine, and barbiturates) can induce or aggravate the disease.

Under normal conditions, the efferent signal of skeletal muscle motor neurons is primarily mediated by the neurotransmitter acetylcholine released at the neuromuscular junction (also called the motor end plate), triggering skeletal muscle contraction. In patients with myasthenia gravis, the release of normal amounts of acetylcholine is impaired, and the sensitivity of receptors is reduced, leading to muscle weakness or even paralysis.

Key Diagnostic Points

Clinically, the onset may be sudden or gradual. Nearly all skeletal muscles can be affected, with the exception of cardiac and smooth muscles. The early manifestation of onset is abnormal easy fatigability in certain skeletal muscles, which is alleviated or resolves after rest or administration of anticholinesterase drugs. The condition exhibits remission and relapse, …

Based on the distribution of affected muscles, the clinical features of deterioration can be classified into the following types:

I. Ocular Muscle Type

Sudden onset, often presenting as unilateral oculomotor nerve palsy, with manifestations such as unilateral ptosis (flaccid drooping), the eyeball positioned inferolaterally, dilated pupil, loss of light reflex, diplopia, and strabismus. Symptoms may improve or resolve after rest. This type is the most common clinically and is often seen in the early stage of the condition.

II. Cervical Muscle Pattern

The lesion affects the cervical trapezius, sternocleidomastoid, and related muscles, presenting with forward head tilt. The patient often requires manual support of the shoulder (scapular girdle). This impairment makes sustained lifting of the upper limbs difficult, compromising tasks such as washing the face and combing hair.

III. Medullary Type (Yansui Xing)

Also known as the bulbar type, when the lesion involves the medulla oblongata, it manifests as dysphagia with inability to swallow continuously, a gradually deepening voice, nasal speech appearing after prolonged talking, weak chewing, accompanied by choking on drinking water, hoarseness, and slurred articulation (blurred speech).

IV. Systemic Type

Onset immediately involves all muscle groups throughout the body, but onset and progression are slow, and remissions may occur. In a few patients, symptoms suddenly deteriorate after several years. In this type, aside from delayed onset, the disease progresses relatively rapidly and is difficult to control with medication.

Fulminant Type

In a very small number of patients, the onset is rapid, with bulbar muscle weakness and dyspnea occurring within days to weeks, leading to myasthenic crisis.

Patients with the above patterns may present with localized lesions alone, or the condition may be aggravated by factors such as the common cold, emotional agitation, overwork, menstruation, childbirth, or surgery. In many cases, the condition spreads to the whole body and deteriorates rapidly within a short period of time.

Examination: If the affected muscle groups are easily fatigued, the condition fluctuates (symptoms milder in the morning and more severe in the evening), and neurological examination reveals no abnormal findings, the diagnosis is not difficult. For suspicious cases, the following tests may be performed:

1. Fatigue Test: Instruct the patient to perform repeated or sustained contraction of the affected muscles (e.g., repeated eye closure and opening, chewing, lifting the arms, making a fist, staring at the doctor’s finger, or holding both arms horizontally) for several dozen repetitions or several dozen seconds. This may induce temporary paralysis of the tested muscle.

2. Pharmacological Test: Intramuscular injection of neostigmine (0.5–1.5 mg) combined with atropine (0.5 mg) leads to significant symptom improvement within 30 minutes, or intravenous administration of edrophonium (10 mg)—first injecting 2 mg, and if no adverse reaction occurs, followed by 8 mg—results in immediate symptomatic relief. A positive test is indicated and aids in diagnosis.

3. Electromyography: May indicate myasthenic changes.

4. CT scan: Can provide accurate diagnosis of thymoma.

Treatment

Ocular Type (Yanji Xing)

I. Acupoints and Needling Methods

1. **GB14 (Yangbai) (bilateral):** Located on the forehead, 1 cun directly above the midpoint of the eyebrow. Select a gauge-30, 1.5 cun filiform needle. Perform routine local disinfection. Insert obliquely toward **Yuyao (EX-HN4)** (at the center of the eyebrow) to a depth of approximately 1.2 cun. Needle sensation: local distension and pain.

2. **BL2 (Zanzhu, bilateral)**: Located at the medial end of the eyebrow, at the supraorbital notch. Use two No. 30 filiform needles of 1.5 cun (40 mm). After routine local disinfection, insert obliquely toward the lateral end of the eyebrow (Yowei point) to a depth of approximately 1.4 cun. Needling sensation: local distension and pain.

3. Yuyao (EX-HN4) (bilateral): Located at the center of the eyebrow. A 30-gauge, 1.5-cun filiform needle is used. After routine local disinfection, insert approximately 1.3 cun along the supraorbital margin toward the supraorbital foramen. Sensation: distension and pain inside the orbit.

4. Taiyang (EX-HN5) (bilateral): Located in the depression about 1 cun posterior to the midpoint between the lateral end of the eyebrow and the outer canthus. Use two filiform needles of gauge 30, 1.5 cun in length. After routine local disinfection, insert obliquely toward the tip of the ear to a depth of approximately 1.4 cun. Sensation: local distension and pain.

2. Methods

The patient is seated. The aforementioned acupoints are needled with the appropriate technique, and electroacupuncture is added. Needles are retained for 40 minutes and then removed. Treatment is administered once daily, with 10 sessions constituting one course. After a 5-day rest, the next course begins.

Systemic Pattern (Quanshenxing)

The acupoints are divided into two groups and can be used alternately.

Group 1:

I. Acupoints and Needling Techniques

1. Jiaji (Ex-B2) points 1–17 (bilateral): Located on the back and lower back, from the 1st thoracic vertebra to the 5th lumbar vertebra, 1 cun lateral to the spinous process of each vertebra, totaling 34 points (17 on each side). Use two 26-gauge, 5-cun-long filiform needles.

Eight filiform needles of gauge #28 and 4 cun in length. After routine local disinfection, begin at the first Jiaji (paravertebral) point (EX-B2). Insert a 5-cun needle transversely downward to a depth of approximately 4.8 cun, then follow with 4-cun needles inserted transversely downward. At the L4–L5 level, insert a 4-cun needle perpendicularly to a depth of about 3 cun. The same procedure is repeated on both sides. Needling sensation: distension and pain in the back and lumbar region.

2. GB30 (Huantiao) (bilateral): Located at the junction of the lateral 1/3 and medial 2/3 of the line connecting the greater trochanter of the femur and the sacral hiatus. After routine local disinfection, a 28-gauge, 4-cun filiform needle is inserted toward the greater sciatic foramen to a depth of approximately 3.8 cun. Needling sensation: radiating numbness and distension along the lower limb and into the sole.

3. BL37 (Yinmen) (bilateral): Located on the line connecting BL36 (Chengfu) and BL40 (Weizhong), 6 cun below BL36 (Chengfu). Use two 3-cun filiform needles of gauge 30. After routine local disinfection, insert perpendicularly about 2.8 cun. Needle sensation: local distension and pain, or radiation down to the lower limb and sole of the foot.

4. Chengshan (BL57) (bilateral): Located at the midpoint of the inverted “V” pattern that appears below the gastrocnemius muscle when the leg is extended (i.e., at the depression under the gastrocnemius belly). Use two 30-gauge, 2-cun filiform needles. Perform routine local disinfection. Insert perpendicularly about 1.8 cun. Needle sensation: local distension and pain.

II. Methods

The patient is placed in a prone position. The aforementioned points are needled according to the standard method, and electroacupuncture is applied. Needles are retained for 40 minutes. After needle removal, cupping is performed for approximately 1 minute. This protocol is alternated with the second group of points. Twenty sessions constitute one course of treatment, administered once every other day, followed by a 5-day rest before resuming acupuncture.

I. Acupoints and Acupuncture Techniques

1. LI17 (Tanding), bilateral: Located on the supraclavicular fossa, 1 cun below LI18 (Futu), at the posterior border of the sternocleidomastoid muscle. Select two 30-gauge filiform needles of 1.5 cun. Routinely disinfect the local area. Insert toward the spinal column to a depth of approximately 1.8 cun. Needle sensation: radiating to the upper arm and hand.

2. **LI4 (Hegu) (bilateral)**: Located on the dorsum of the hand, between the 1st and 2nd metacarpal bones, approximately at the midpoint of the radial side of the 2nd metacarpal bone. Use two 30-gauge, 2-cun filiform needles. After routine local disinfection, insert the needle obliquely toward SI3 (Houxi) to a depth of about 1.8 cun. Needling sensation: local distension and pain.

3. Qianzheng (Extra, Bilateral): Located 0.5 cun anterior to the earlobe, level with the midpoint of the earlobe. Use two 30-gauge, 1.5 cun filiform needles. After routine local disinfection, insert obliquely toward the tip of the nose to a depth of approximately 1.3 cun. Needle sensation: local distension and pain.

4. Shangwan (CV13): Located on the anterior midline, 5 cun above the umbilicus. Using a 28-gauge, 4-cun filiform needle, after routine local disinfection, insert transversely toward Shenque (CV8) to a depth of approximately 3.8 cun. Needling sensation: local distension and pain.

5. ST36 (Zusanli) (bilateral): Located 3 cun below ST35 (Dubi), one finger-breadth (middle finger) lateral to the anterior crest of the tibia. Use two filiform needles, size 30 (gauge 30), 2 cun in length. After routine local disinfection, insert perpendicularly to a depth of approximately 1.8 cun. Sensation: Local distension and soreness, or radiation to the dorsum of the foot.

6. SP6 (Sanyinjiao) (bilateral): Located 3 cun directly above the medial malleolus, on the posterior border of the medial aspect of the tibia. Use two 30-gauge, 2-cun filiform needles. After routine local disinfection, insert perpendicularly approximately 1.6 cun toward GB39 (Xuanzhong). Needling sensation: local distension and pain.

2. Methods

The patient assumes a supine position. The aforementioned points are needled according to the protocol with electroacupuncture, and the needles are retained for 40 minutes before removal. Points suitable for cupping receive cupping for approximately 1 minute. This treatment is alternated with the first group of points. Twenty sessions (10 per group) constitute one course of treatment. After a 5-day rest, the treatment is resumed.

【Remarks】

Myasthenia Gravis is a clinically common and quite refractory stubborn disease. Electroacupuncture treatment yields relatively good results for the ocular type. It also has some effect on other types, but a portion of cases respond poorly. In such instances, combining electroacupuncture with Neostigmine tablets (15 mg per dose, three times daily orally) can achieve better outcomes than using either method alone. For patients with myasthenic crisis, acupuncture should be used as an adjunctive therapy alongside inpatient treatment to further enhance efficacy. Since the condition of Myasthenia Gravis is complex and variable, the acupoints selected must be flexibly adjusted—adding or reducing points as needed—to attain better therapeutic results.

Autoimmune Pathogenesis and the Thymic Connection

Myasthenia gravis autoimmune disorder arises from a breakdown in immune tolerance, leading to the production of autoantibodies that target the acetylcholine receptors at the neuromuscular junction. This disruption in cholinergic transmission impairs voluntary muscle contraction, resulting in characteristic fluctuating weakness. A central feature of the disease is the thymoma and myasthenia gravis connection. The thymus, a primary lymphoid organ responsible for T-cell maturation and immune self-tolerance, is frequently abnormal in patients—either hyperplastic or tumorous. In thymoma-associated myasthenia gravis, the neoplastic thymic epithelium likely presents self-antigens aberrantly, fostering an environment where autoreactive T-cells escape deletion and subsequently help B-cells produce pathogenic anti-acetylcholine receptor antibodies. This intimate link between thymic pathology and autoimmunity underscores the rationale for thymectomy as a therapeutic intervention. The molecular mechanisms involve epitope spreading and cross-reactivity, further entrenching the autoimmune response. Understanding this relationship clarifies why thymoma is a strong risk factor and why thymic imaging is mandatory at diagnosis. The chronic nature of the disease requires long-term immunomodulation, but addressing the thymic source can alter the course in many patients.

Clinical Fatigue and Infectious Triggers

One of the most debilitating symptoms is myasthenia gravis fatigue causes, which stems not from central nervous system exhaustion but from peripheral neuromuscular block. Repetitive muscle activity depletes the limited acetylcholine available, leading to progressive weakening that improves with rest. This “fatigue” is actually a hallmark of impaired neuromuscular transmission and is objectively measured by decremental responses on repetitive nerve stimulation. Besides the mechanical fatigue, systemic inflammation and autoantibody-mediated damage contribute to a sense of lassitude. Importantly, myasthenia gravis triggers infection are well-documented: bacterial or viral illnesses can abruptly worsen symptoms, occasionally precipitating a myasthenic crisis. Infections stimulate the immune system, potentially increasing autoantibody production and disrupting the fragile balance at the neuromuscular junction. Fever and inflammatory cytokines may also interfere with acetylcholine release or muscle membrane stability. Thus, infections are a major trigger for exacerbations and must be managed promptly with close monitoring of respiratory muscle function. Prophylactic immunization and prompt antibiotic therapy are recommended. Understanding these triggers and the mechanism of fatigue is crucial for patient counseling and for designing rehabilitation strategies that conserve energy while preventing crises.