ArticleFrontiers in immunology2026
FcRn antagonist and C5 complement inhibitor as early rescue strategies in severe Myasthenia Gravis: a two-case report.
Article in Frontiers in immunology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Myasthenia gravis (MG) is an autoimmune neuromuscular disorder in which approximately 10-15% of patients with generalized AChR antibody-positive MG develop refractoriness to standard immunosuppressive therapies. Advanced therapeutic strategies, including FcRn antagonists and C5 complement inhibitors, have demonstrated early and sustained clinical efficacy in pivotal phase 3 trials. However, evidence supporting their early use in complex clinical scenarios remains limited. Case report: We report two cases of severe generalized MG in which early initiation of advanced therapies was associated with rapid clinical stabilization. In the first case, a 75-year-old man with thymoma-associated MG and severe bulbar involvement refractory (MG-ADL: 11) to plasma exchange (PLEX) and intravenous immunoglobulins (IVIg), and unable to continue azathioprine due to adverse events, received off-label efgartigimod preoperatively. Near-complete resolution of bulbar symptoms was observed within 48 hours, enabling robot-assisted thymectomy on day 4 following the first infusion, with sustained neurological improvement at one-month follow-up (MG-ADL score: 2). In the second case, a 74-year-old man with severe refractory bulbar MG requiring nasogastric tube feeding (MG-ADL: 13) and subsequent percutaneous endoscopic gastrostomy (PEG) was treated with ravulizumab after an incomplete response to PLEX, IVIg, corticosteroids, and azathioprine. MG-ADL decreased from 9 at treatment initiation to 5 after two infusions of ravulizumab, and complete recovery of swallowing function allowed PEG removal at 18-week follow-up, with achievement of minimal symptom expression (MG-ADL score: 0). Discussion: These cases highlight the potential role of early and targeted use of advanced immunotherapies in severe, refractory MG, including as a bridging strategy to thymectomy. Further prospective studies are needed to define optimal criteria and timing for early integration of these agents into the therapeutic algorithm.
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