{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T19:50:59Z","timestamp":1791402659009,"version":"4.3.3"},"reference-count":87,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2023,3,10]],"date-time":"2023-03-10T00:00:00Z","timestamp":1678406400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Neurology International"],"abstract":"<jats:p>Myasthenia gravis (MG) is an autoimmune neuromuscular disease characterized by fluctuating weakness of the skeletal muscles. Although antibodies against the neuromuscular junction components are recognized, the MG pathogenesis remains unclear, even if with a well-known multifactorial character. However, the perturbations of human microbiota have been recently suggested to contribute to MG pathogenesis and clinical course. Accordingly, some products derived from commensal flora have been demonstrated to have anti-inflammatory effects, while other have been shown to possess pro-inflammatory properties. In addition, patients with MG when compared with age-matched controls showed a distinctive composition in the oral and gut microbiota, with a typical increase in Streptococcus and Bacteroides and a reduction in Clostridia as well as short-chain fatty acid reduction. Moreover, restoring the gut microbiota perturbation has been evidenced after the administration of probiotics followed by an improvement of symptoms in MG cases. To highlight the role of the oral and gut microbiota in MG pathogenesis and clinical course, here, the current evidence has been summarized and reviewed.<\/jats:p>","DOI":"10.3390\/neurolint15010026","type":"journal-article","created":{"date-parts":[[2023,3,13]],"date-time":"2023-03-13T06:52:13Z","timestamp":1678690333000},"page":"392-404","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["The Role of Human Microbiota in Myasthenia Gravis: A Narrative Review"],"prefix":"10.3390","volume":"15","author":[{"given":"Giuseppe","family":"Schir\u00f2","sequence":"first","affiliation":[{"name":"Neurology Unit, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0035-5859","authenticated-orcid":false,"given":"Salvatore","family":"Iacono","sequence":"additional","affiliation":[{"name":"Neurology Unit, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5393-1007","authenticated-orcid":false,"given":"Carmela Rita","family":"Balistreri","sequence":"additional","affiliation":[{"name":"Cellular and Molecular Laboratory, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,3,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1038\/nature09944","article-title":"Enterotypes of the Human Gut Microbiome","volume":"473","author":"Arumugam","year":"2011","journal-title":"Nature"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1605","DOI":"10.1136\/gut.2007.133603","article-title":"High-Throughput Diversity and Functionality Analysis of the Gastrointestinal Tract Microbiota","volume":"57","author":"Zoetendal","year":"2008","journal-title":"Gut"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"569","DOI":"10.1126\/science.1241165","article-title":"The Microbial Metabolites, Short-Chain Fatty Acids, Regulate Colonic T Reg Cell Homeostasis","volume":"341","author":"Smith","year":"2013","journal-title":"Science"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1111\/imm.12896","article-title":"Adaptive Immune Education by Gut Microbiota Antigens","volume":"154","author":"Zhao","year":"2018","journal-title":"Immunology"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"665","DOI":"10.1016\/j.cell.2018.08.049","article-title":"A Neural Circuit for Gut-Induced Reward","volume":"175","author":"Han","year":"2018","journal-title":"Cell"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1087","DOI":"10.1126\/science.abi6087","article-title":"Signaling Inflammation across the Gut-Brain Axis","volume":"374","author":"Agirman","year":"2021","journal-title":"Science"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1146\/annurev-immunol-071219-125715","article-title":"Microbiota Metabolites in Health and Disease","volume":"38","author":"McCarville","year":"2020","journal-title":"Annu. Rev. Immunol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1038\/s41398-018-0240-5","article-title":"Gut Microbiota Regulates Mouse Behaviors through Glucocorticoid Receptor Pathway Genes in the Hippocampus","volume":"8","author":"Luo","year":"2018","journal-title":"Transl. Psychiatry"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"111572","DOI":"10.1016\/j.mce.2022.111572","article-title":"Short Chain Fatty Acids: Microbial Metabolites for Gut-Brain Axis Signalling","volume":"546","author":"Collins","year":"2022","journal-title":"Mol. Cell Endocrinol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1016\/j.molmed.2021.12.006","article-title":"Crosstalk between Bile Acid-Activated Receptors and Microbiome in Entero-Hepatic Inflammation","volume":"28","author":"Thibaut","year":"2022","journal-title":"Trends Mol. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"427","DOI":"10.1016\/j.tim.2011.06.005","article-title":"Investigating the Biological and Clinical Significance of Human Dysbioses","volume":"19","author":"Frank","year":"2011","journal-title":"Trends Microbiol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"737","DOI":"10.1016\/j.coph.2009.06.016","article-title":"Interplay between Obesity and Associated Metabolic Disorders: New Insights into the Gut Microbiota","volume":"9","author":"Cani","year":"2009","journal-title":"Curr. Opin. Pharmacol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"58","DOI":"10.3945\/ajcn.110.010132","article-title":"Energy-Balance Studies Reveal Associations between Gut Microbes, Caloric Load, and Nutrient Absorption in Humans","volume":"94","author":"Jumpertz","year":"2011","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1782","DOI":"10.1053\/j.gastro.2011.06.072","article-title":"Gastrointestinal Microbiome Signatures of Pediatric Patients with Irritable Bowel Syndrome","volume":"141","author":"Saulnier","year":"2011","journal-title":"Gastroenterology"},{"key":"ref_15","first-page":"74","article-title":"The Microbiome in Autoimmune Diseases","volume":"195","author":"Shoenfeld","year":"2019","journal-title":"Clin. Exp. Immunol."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Fanara, S., Aprile, M., Iacono, S., Schir\u00f2, G., Bianchi, A., Brighina, F., Dominguez, L.J., Ragonese, P., and Salemi, G. (2021). The Role of Nutritional Lifestyle and Physical Activity in Multiple Sclerosis Pathogenesis and Management: A Narrative Review. Nutrients, 13.","DOI":"10.3390\/nu13113774"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Thye, A.Y.K., Law, J.W.F., Tan, L.T.H., Thurairajasingam, S., Chan, K.G., Letchumanan, V., and Lee, L.H. (2022). Exploring the Gut Microbiome in Myasthenia Gravis. Nutrients, 14.","DOI":"10.3390\/nu14081647"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Magne, F., Gotteland, M., Gauthier, L., Zazueta, A., Pesoa, S., Navarrete, P., and Balamurugan, R. (2020). The Firmicutes\/Bacteroidetes Ratio: A Relevant Marker of Gut Dysbiosis in Obese Patients?. Nutrients, 12.","DOI":"10.3390\/nu12051474"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"5721","DOI":"10.1128\/JCM.43.11.5721-5732.2005","article-title":"Defining the Normal Bacterial Flora of the Oral Cavity","volume":"43","author":"Aas","year":"2005","journal-title":"J. Clin. Microbiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"3770","DOI":"10.1128\/JB.183.12.3770-3783.2001","article-title":"Bacterial Diversity in Human Subgingival Plaque","volume":"183","author":"Paster","year":"2001","journal-title":"J. Bacteriol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"5002","DOI":"10.1128\/JB.00542-10","article-title":"The Human Oral Microbiome","volume":"192","author":"Dewhirst","year":"2010","journal-title":"J. Bacteriol."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Zangeneh, Z., Abdi-Ali, A., Khamooshian, K., Alvandi, A., and Abiri, R. (2021). Bacterial Variation in the Oral Microbiota in Multiple Sclerosis Patients. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0260384"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e299","DOI":"10.1212\/WNL.0000000000008688","article-title":"Myasthenic Crisis Demanding Mechanical Ventilation","volume":"94","author":"Neumann","year":"2020","journal-title":"Neurology"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2019","DOI":"10.1007\/s10482-020-01474-7","article-title":"Human Gut Microbiota\/Microbiome in Health and Diseases: A Review","volume":"113","author":"Gomaa","year":"2020","journal-title":"Antonie van Leeuwenhoek"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Parolini, C. (2019). Effects of Fish N-3 PUFAs on Intestinal Microbiota and Immune System. Mar. Drugs, 17.","DOI":"10.3390\/md17060374"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1239","DOI":"10.1093\/advances\/nmaa181","article-title":"Diet and the Microbiota\u2013Gut\u2013Brain Axis: Sowing the Seeds of Good Mental Health","volume":"12","author":"Berding","year":"2021","journal-title":"Adv. Nutr."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1177\/1559827621993748","article-title":"Five-Month Trial of Whole-Food Plant-Based Diet in a Patient With Coexisting Myasthenia Gravis and Lambert-Eaton Myasthenic Syndrome","volume":"15","author":"Peter","year":"2021","journal-title":"Am. J. Lifestyle Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1214","DOI":"10.1126\/science.aac8469","article-title":"Gut Microbiota and Aging","volume":"350","author":"Jeffery","year":"2015","journal-title":"Science"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1186\/1750-1326-9-36","article-title":"Diet and Exercise Orthogonally Alter the Gut Microbiome and Reveal Independent Associations with Anxiety and Cognition","volume":"9","author":"Kang","year":"2014","journal-title":"Mol. Neurodegener."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1768","DOI":"10.3389\/fimmu.2017.01768","article-title":"Exercise Prevents Enhanced Postoperative Neuroinflammation and Cognitive Decline and Rectifies the Gut Microbiome in a Rat Model of Metabolic Syndrome","volume":"8","author":"Feng","year":"2017","journal-title":"Front. Immunol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"747","DOI":"10.1249\/MSS.0000000000001495","article-title":"Exercise Alters Gut Microbiota Composition and Function in Lean and Obese Humans","volume":"50","author":"Allen","year":"2018","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1159\/000443360","article-title":"Effects of Antibiotics on Gut Microbiota","volume":"34","author":"Lange","year":"2016","journal-title":"Dig. Dis."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"406","DOI":"10.1002\/ncp.10489","article-title":"Role of Microbiome and Antibiotics in Autoimmune Diseases","volume":"35","author":"Vangoitsenhoven","year":"2020","journal-title":"Nutr. Clin. Pract."},{"key":"ref_34","first-page":"26191","article-title":"Dysbiosis of the Gut Microbiota in Disease","volume":"26","author":"Carding","year":"2015","journal-title":"Microb. Ecol. Health Dis."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"2972","DOI":"10.1111\/j.1572-0241.2008.01992.x","article-title":"Bacterial Overgrowth and Irritable Bowel Syndrome: Unifying Hypothesis or a Spurious Consequence of Proton Pump Inhibitors?","volume":"103","author":"Spiegel","year":"2008","journal-title":"Am. J. Gastroenterol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"483","DOI":"10.1016\/j.cgh.2012.12.011","article-title":"Proton Pump Inhibitor Use and the Risk of Small Intestinal Bacterial Overgrowth: A Meta-Analysis","volume":"11","author":"Lo","year":"2013","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2627","DOI":"10.3389\/fmicb.2018.02627","article-title":"Altered Gut Microbiota in Myasthenia Gravis","volume":"9","author":"Qiu","year":"2018","journal-title":"Front. Microbiol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"991","DOI":"10.15252\/embr.201338233","article-title":"Regulatory T Cells Suppress CD4+ T Cells through NFAT-Dependent Transcriptional Mechanisms","volume":"15","author":"Shin","year":"2014","journal-title":"EMBO Rep."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"14384","DOI":"10.1038\/s41598-018-32700-y","article-title":"Fecal Microbiota Profile in a Group of Myasthenia Gravis Patients","volume":"8","author":"Moris","year":"2018","journal-title":"Sci. Rep."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"17562864211035657","DOI":"10.1177\/17562864211035657","article-title":"Gut Bacterial Microbiota in Patients with Myasthenia Gravis: Results from the MYBIOM Study","volume":"14","author":"Totzeck","year":"2021","journal-title":"Ther. Adv. Neurol. Disord."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Liu, P., Jiang, Y., Gu, S., Xue, Y., Yang, H., Li, Y., Wang, Y., Yan, C., Jia, P., and Lin, X. (2021). Metagenome-Wide Association Study of Gut Microbiome Revealed Potential Microbial Marker Set for Diagnosis of Pediatric Myasthenia Gravis. BMC Med., 19.","DOI":"10.1186\/s12916-021-02034-0"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1137","DOI":"10.1097\/MIB.0000000000000750","article-title":"Future Directions and Methods For IBD Research Animal Models","volume":"22","author":"Degruttola","year":"2016","journal-title":"Inflamm. Bowel Dis."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"570","DOI":"10.1016\/j.ccell.2018.03.015","article-title":"The Influence of the Gut Microbiome on Cancer, Immunity, and Cancer Immunotherapy","volume":"33","author":"Gopalakrishnan","year":"2018","journal-title":"Cancer Cell"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"2341","DOI":"10.1111\/ajt.16522","article-title":"Microbiota and Immunoregulation: A Focus on Regulatory B Lymphocytes and Transplantation","volume":"21","author":"Pacaud","year":"2021","journal-title":"Am. J. Transplant."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"639","DOI":"10.3389\/fimmu.2015.00639","article-title":"The Treg\/Th17 Axis: A Dynamic Balance Regulated by the Gut Microbiome","volume":"6","author":"Omenetti","year":"2015","journal-title":"Front. Immunol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"3100","DOI":"10.3389\/fimmu.2019.03100","article-title":"Treg Heterogeneity, Function, and Homeostasis","volume":"10","author":"Shevyrev","year":"2020","journal-title":"Front. Immunol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12974-017-0892-8","article-title":"Regulatory T Cells in Multiple Sclerosis and Myasthenia Gravis","volume":"14","author":"Danikowski","year":"2017","journal-title":"J. Neuroinflam."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1111\/nyas.13591","article-title":"An Imbalance between Regulatory T Cells and T Helper 17 Cells in Acetylcholine Receptor-Positive Myasthenia Gravis Patients","volume":"1413","author":"Villegas","year":"2018","journal-title":"Ann. N. Y. Acad. Sci."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"859","DOI":"10.1586\/1744666X.2015.1047345","article-title":"The Role of T Regulatory Cells in Immunopathogenesis of Myasthenia Gravis: Implications for Therapeutics","volume":"11","author":"Kasapoglu","year":"2015","journal-title":"Expert Rev. Clin. Immunol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"28484","DOI":"10.1038\/srep28484","article-title":"Multiple Sclerosis Patients Have a Distinct Gut Microbiota Compared to Healthy Controls","volume":"6","author":"Chen","year":"2016","journal-title":"Sci. Rep."},{"key":"ref_51","first-page":"4835189","article-title":"Intestinal Dysbiosis and Rheumatoid Arthritis: A Link between Gut Microbiota and the Pathogenesis of Rheumatoid Arthritis","volume":"2017","year":"2017","journal-title":"J. Immunol. Res."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"22269","DOI":"10.18632\/oncotarget.25170","article-title":"Administration of Bifidobacterium and Lactobacillus Strains Modulates Experimental Myasthenia Gravis and Experimental Encephalomyelitis in Lewis Rats","volume":"9","author":"Consonni","year":"2018","journal-title":"Oncotarget"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1016\/j.htct.2020.03.002","article-title":"A Review of Hematopoietic Stem Cell Transplantation for Autoimmune Diseases: Multiple Sclerosis, Systemic Sclerosis and Crohn\u2019s Disease. Position Paper of the Brazilian Society of Bone Marrow Transplantation","volume":"43","author":"Oliveira","year":"2021","journal-title":"Hematol. Transfus. Cell Ther."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1111\/imm.12765","article-title":"Intestinal Dysbiosis and Probiotic Applications in Autoimmune Diseases","volume":"152","author":"Leite","year":"2017","journal-title":"Immunology"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"5620","DOI":"10.1128\/IAI.73.9.5620-5627.2005","article-title":"Bacteroides Fragilis-Derived Lipopolysaccharide Produces Cell Activation and Lethal Toxicity via Toll-like Receptor 4","volume":"73","author":"Mancuso","year":"2005","journal-title":"Infect Immun."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"1282","DOI":"10.1038\/nature08530","article-title":"Regulation of Inflammatory Responses by Gut Microbiota and Chemoattractant Receptor GPR43","volume":"461","author":"Maslowski","year":"2009","journal-title":"Nature"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"411","DOI":"10.3920\/BM2020.0057","article-title":"Short Chain Fatty Acids in Human Gut and Metabolic Health","volume":"11","author":"Blaak","year":"2020","journal-title":"Benef. Microbes"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1016\/j.smim.2013.10.002","article-title":"Peripheral Education of the Immune System by the Colonic Microbiota","volume":"25","author":"Kuhn","year":"2013","journal-title":"Semin. Immunol."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1126\/science.1198469","article-title":"Induction of Colonic Regulatory T Cells by Indigenous Clostridium Species","volume":"331","author":"Atarashi","year":"2011","journal-title":"Science"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"1507","DOI":"10.1177\/0963689719873890","article-title":"The Gut Microbiota in Multiple Sclerosis: An Overview of Clinical Trials","volume":"28","author":"Schepici","year":"2019","journal-title":"Cell Transpl."},{"key":"ref_61","doi-asserted-by":"crossref","unstructured":"Nicholson, J.S., and Landry, K.S. (2022). Oral Dysbiosis and Neurodegenerative Diseases: Correlations and Potential Causations. Microorganisms, 10.","DOI":"10.3390\/microorganisms10071326"},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1111\/ene.13819","article-title":"Multiple Sclerosis\u2014A Review","volume":"26","author":"Dobson","year":"2019","journal-title":"Eur. J. Neurol."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"2196","DOI":"10.3389\/fmicb.2020.564579","article-title":"Differential Gut Microbiota and Fecal Metabolites Related With the Clinical Subtypes of Myasthenia Gravis","volume":"11","author":"Tan","year":"2020","journal-title":"Front. Microbiol."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"104714","DOI":"10.1016\/j.nbd.2019.104714","article-title":"The Microbiota-Immune Axis as a Central Mediator of Gut-Brain Communication","volume":"136","author":"Fung","year":"2020","journal-title":"Neurobiol. Dis."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"938360","DOI":"10.3389\/fneur.2022.938360","article-title":"Oral Microbiota Profile in a Group of Anti-AChR Antibody-Positive Myasthenia Gravis Patients","volume":"13","author":"Huang","year":"2022","journal-title":"Front. Neurol."},{"key":"ref_66","doi-asserted-by":"crossref","unstructured":"Couvigny, B., de Wouters, T., Kaci, G., Jacouton, E., Delorme, C., Dor\u00e9, J., Renault, P., Blotti\u00e8re, H.M., Gu\u00e9don, E., and Lapaque, N. (2015). Commensal Streptococcus Salivarius Modulates PPAR\u03b3 Transcriptional Activity in Human Intestinal Epithelial Cells. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0125371"},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"2317","DOI":"10.1101\/gr.096651.109","article-title":"The NIH Human Microbiome Project","volume":"19","author":"Peterson","year":"2009","journal-title":"Genome Res."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"201","DOI":"10.3109\/08916934.2014.992517","article-title":"B Cells Produce Less IL-10, IL-6 and TNF-\u03b1 in Myasthenia Gravis","volume":"48","author":"Yilmaz","year":"2015","journal-title":"Autoimmunity"},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1016\/j.nmd.2016.10.012","article-title":"Analysis of TNF-Related Apoptosis-Inducing Ligand and Receptors and Implications in Thymus Biology and Myasthenia Gravis","volume":"27","author":"Kanatli","year":"2017","journal-title":"Neuromuscul. Disord."},{"key":"ref_70","doi-asserted-by":"crossref","unstructured":"Sheikh, S., Alvi, U., Soliven, B., and Rezania, K. (2021). Drugs That Induce or Cause Deterioration of Myasthenia Gravis: An Update. J. Clin. Med., 10.","DOI":"10.3390\/jcm10071537"},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"785040","DOI":"10.3389\/fneur.2022.785040","article-title":"Effect of Fufang Huangqi Decoction on the Gut Microbiota in Patients With Class I or II Myasthenia Gravis","volume":"13","author":"Chen","year":"2022","journal-title":"Front. Neurol."},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"1901441","DOI":"10.1002\/advs.201901441","article-title":"Perturbed Microbial Ecology in Myasthenia Gravis: Evidence from the Gut Microbiome and Fecal Metabolome","volume":"31","author":"Zheng","year":"2019","journal-title":"Adv. Sci."},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"803101","DOI":"10.3389\/fimmu.2021.803101","article-title":"Gut Microbiota as Regulators of Th17\/Treg Balance in Patients With Myasthenia Gravis","volume":"12","author":"Chen","year":"2021","journal-title":"Front. Immunol."},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"475","DOI":"10.1016\/S1474-4422(09)70063-8","article-title":"Autoimmune Myasthenia Gravis: Emerging Clinical and Biological Heterogeneity","volume":"8","author":"Meriggioli","year":"2009","journal-title":"Lancet Neurol."},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1016\/j.jaut.2013.12.004","article-title":"A Comprehensive Analysis of the Epidemiology and Clinical Characteristics of Anti-LRP4 in Myasthenia Gravis","volume":"52","author":"Zisimopoulou","year":"2014","journal-title":"J. Autoimmun."},{"key":"ref_76","first-page":"e9184","article-title":"A Review of Psychiatric Comorbidity in Myasthenia Gravis","volume":"12","author":"Law","year":"2020","journal-title":"Cureus"},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1007\/s13760-019-01102-w","article-title":"A Study of Comorbidities in Myasthenia Gravis","volume":"120","author":"Misra","year":"2020","journal-title":"Acta Neurol. Belg."},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"553626","DOI":"10.3389\/fneur.2020.553626","article-title":"Determinants of Quality of Life in Myasthenia Gravis Patients","volume":"11","author":"Szczudlik","year":"2020","journal-title":"Front. Neurol."},{"key":"ref_79","doi-asserted-by":"crossref","unstructured":"Iacono, S., Stefano, V.D., Costa, V., Schir\u00f2, G., Lupica, A., Maggio, B., Norata, D., Pignolo, A., Brighina, F., and Monastero, R. (2023). Frequency and Correlates of Mild Cognitive Impairment in Myasthenia Gravis. Brain Sci., 13.","DOI":"10.3390\/brainsci13020170"},{"key":"ref_80","first-page":"1118","article-title":"Altered Metabolism of the Microbiota\u2013Gut\u2013Brain Axis Is Linked With Comorbid Anxiety in Fecal Recipient Mice of Myasthenia Gravis","volume":"13","author":"Zhang","year":"2022","journal-title":"Front. Microbiol."},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1111\/nyas.13567","article-title":"Gut Microbiota and Probiotics: Novel Immune System Modulators in Myasthenia Gravis?","volume":"1413","author":"Rinaldi","year":"2018","journal-title":"Ann. N. Y. Acad. Sci."},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"2949","DOI":"10.3389\/fimmu.2019.02949","article-title":"Therapeutic Effect of Bifidobacterium Administration on Experimental Autoimmune Myasthenia Gravis in Lewis Rats","volume":"10","author":"Rinaldi","year":"2019","journal-title":"Front. Immunol."},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1016\/j.expneurol.2015.03.010","article-title":"Standardization of the Experimental Autoimmune Myasthenia Gravis (EAMG) Model by Immunization of Rats with Torpedo Californica Acetylcholine Receptors\u2014Recommendations for Methods and Experimental Designs","volume":"270","author":"Losen","year":"2015","journal-title":"Exp. Neurol."},{"key":"ref_84","doi-asserted-by":"crossref","unstructured":"Chae, C.S., Kwon, H.K., Hwang, J.S., Kim, J.E., and Im, S.H. (2012). Prophylactic Effect of Probiotics on the Development of Experimental Autoimmune Myasthenia Gravis. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0052119"},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"1758","DOI":"10.1039\/c0np00005a","article-title":"Anti-Influenza Agents from Traditional Chinese Medicine","volume":"27","author":"Ge","year":"2010","journal-title":"Nat. Prod. Rep."},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"360","DOI":"10.1007\/s11684-016-0455-x","article-title":"Barriers and Countermeasures in Developing Traditional Chinese Medicine in Europe","volume":"10","author":"Liu","year":"2016","journal-title":"Front. Med."},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"968","DOI":"10.3201\/eid2505.181591","article-title":"Severe Myasthenic Manifestation of Leptospirosis Associated with New Sequence Type of Leptospira Interrogans","volume":"25","author":"Tomschik","year":"2019","journal-title":"Emerg. Infect. 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