{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,13]],"date-time":"2025-11-13T07:00:53Z","timestamp":1763017253915},"reference-count":20,"publisher":"Wiley","issue":"6","license":[{"start":{"date-parts":[[2013,5,11]],"date-time":"2013-05-11T00:00:00Z","timestamp":1368230400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Muscle and Nerve"],"published-print":{"date-parts":[[2013,6]]},"abstract":"<jats:title>ABSTRACT<\/jats:title><jats:sec><jats:title>Introduction<\/jats:title><jats:p>We describe a patient with stable generalized myasthenia gravis who presented with new onset severe ophthalmoplegia and ptosis after initiation of voriconazole for aspergillosis.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Ligand\u2010protein docking software was used to simulate the interaction of voriconazole with the acetylcholine receptor (<jats:styled-content style=\"fixed-case\">AChR<\/jats:styled-content>). We tested voriconazole binding to <jats:styled-content style=\"fixed-case\">AChR<\/jats:styled-content> in comparison to high affinity and neutral compounds.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>There was no clinical improvement after intravenous immunoglobulin infusion and plasmapheresis. However, the patient improved slowly after withdrawal of voriconazole. Based on our results, voriconazole binds favorably to <jats:styled-content style=\"fixed-case\">AChR<\/jats:styled-content> and may putatively block muscle nicotinic <jats:styled-content style=\"fixed-case\">AChRs<\/jats:styled-content>. Other theoretical explanations include blocking potassium channels and reducing their intracellular trafficking.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>The mechanisms involved in ocular exacerbation may be multi\u2010factorial, reflecting the intricate dynamics of the neuromuscular junction. It is important to consider medications that harbor pyridine or pyrimidine moieties as potential causes of exacerbation in myasthenic patients, especially those who present with ocular symptoms. Muscle Nerve 47: 928\u2013930, 2013<\/jats:p><\/jats:sec>","DOI":"10.1002\/mus.23751","type":"journal-article","created":{"date-parts":[[2012,12,14]],"date-time":"2012-12-14T07:49:14Z","timestamp":1355471354000},"page":"928-930","source":"Crossref","is-referenced-by-count":9,"title":["Exacerbation of myasthenia gravis with voriconazole"],"prefix":"10.1002","volume":"47","author":[{"given":"Raed","family":"Azzam","sequence":"first","affiliation":[{"name":"Neuromuscular Center Department of Neurology and Neurological Institute University Hospitals Case Medical Center 11100 Euclid Avenue Cleveland Ohio 44106\u20105098 USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aasef G.","family":"Shaikh","sequence":"additional","affiliation":[{"name":"Neuromuscular Center Department of Neurology and Neurological Institute University Hospitals Case Medical Center 11100 Euclid Avenue Cleveland Ohio 44106\u20105098 USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alessandro","family":"Serra","sequence":"additional","affiliation":[{"name":"Neuromuscular Center Department of Neurology and Neurological Institute University Hospitals Case Medical Center 11100 Euclid Avenue Cleveland Ohio 44106\u20105098 USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bashar","family":"Katirji","sequence":"additional","affiliation":[{"name":"Neuromuscular Center Department of Neurology and Neurological Institute University Hospitals Case Medical Center 11100 Euclid Avenue Cleveland Ohio 44106\u20105098 USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2013,5,11]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1002\/j.1875-9114.1997.tb03085.x"},{"key":"e_1_2_7_3_1","doi-asserted-by":"publisher","DOI":"10.1186\/1758-2946-1-15"},{"key":"e_1_2_7_4_1","volume-title":"Side effects of telithromycin and voriconazole are attributable to nicotinic acetylcholine receptor interaction","author":"Bertrand D BS","year":"2011"},{"key":"e_1_2_7_5_1","volume-title":"Computational intelligence in bioinformatics","author":"Fogel GB","year":"2008"},{"key":"e_1_2_7_6_1","doi-asserted-by":"publisher","DOI":"10.2183\/pjab.87.41"},{"key":"e_1_2_7_7_1","doi-asserted-by":"publisher","DOI":"10.1007\/BF02828147"},{"key":"e_1_2_7_8_1","doi-asserted-by":"publisher","DOI":"10.1126\/science.7384786"},{"key":"e_1_2_7_9_1","doi-asserted-by":"publisher","DOI":"10.1006\/dbio.1996.0253"},{"key":"e_1_2_7_10_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0028-3908(96)00103-7"},{"key":"e_1_2_7_11_1","doi-asserted-by":"publisher","DOI":"10.1002\/mus.22273"},{"key":"e_1_2_7_12_1","doi-asserted-by":"publisher","DOI":"10.1002\/ana.410410404"},{"key":"e_1_2_7_13_1","first-page":"39","article-title":"Drug\u2010induced myasthenic syndromes","volume":"100","author":"Kaeser HE","year":"1984","journal-title":"Acta Neurol Scand Suppl"},{"key":"e_1_2_7_14_1","first-page":"383","article-title":"Interaction of aminoglycoside antibiotics and lithium at the neuromuscular junctions","volume":"18","author":"Dehpour AR","year":"1992","journal-title":"Drugs Exp Clin Res"},{"key":"e_1_2_7_15_1","doi-asserted-by":"publisher","DOI":"10.1007\/BF02828147"},{"key":"e_1_2_7_16_1","doi-asserted-by":"publisher","DOI":"10.1086\/509646"},{"key":"e_1_2_7_17_1","volume-title":"Side effects of telithromycin and voriconazole are attributable to nicotinic acetylcholine receptor interaction","author":"Bertrand D","year":"2011"},{"key":"e_1_2_7_18_1","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.28.3.266"},{"key":"e_1_2_7_19_1","doi-asserted-by":"publisher","DOI":"10.1172\/JCI30836"},{"key":"e_1_2_7_20_1","doi-asserted-by":"publisher","DOI":"10.1038\/sj.bjp.0707537"},{"key":"e_1_2_7_21_1","doi-asserted-by":"publisher","DOI":"10.1016\/0012-1606(81)90392-4"}],"container-title":["Muscle &amp; 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