Multidomain Fatigue, Cognitive, and Quality of Life Observations in Generalized Myasthenia Gravis Under Ravulizumab: A Case Series

This study aimed to explore fatigue and cognitive features as underrecognized non-motor dimensions in myasthenia gravis (MG), and to describe multidomain observations following initiation of ravulizumab in older adults with generalized myasthenia gravis (gMG). Three acetylcholine receptor antibody-positive older adults with gMG underwent a standardized multidomain evaluation, including clinical outcomes, patient-reported measures of fatigue and quality of life, and performance-based cognitive assessment. Clinical severity was assessed using the Myasthenia Gravis Activities of Daily Living (MG-ADL) scale and the Quantitative Myasthenia Gravis (QMG) score. Fatigue was assessed using the Neuro-QoL Fatigue scale and the Modified Fatigue Impact Scale (MFIS), and quality of life using the Myasthenia Gravis Quality of Life scale (MG-QoL). Cognitive performance was assessed using the Trail Making Test (TMT). Assessments were performed at baseline and repeated after approximately 12 months and analyzed descriptively. Three patients were enrolled. At baseline, MG-ADL scores ranged from 9 to 10 and QMG scores from 10 to 17. Neuro-QoL Fatigue T-scores ranged from 66 to 70, and MFIS total scores from 18 to 43, with MFIS cognitive subscores ranging from 5 to 21. TMT part B completion times ranged from 284 to 300 s in two patients, while one patient was not evaluable. At follow-up, MG-ADL scores were 7, MG-QoL scores ranged from 10 to 14 (from baseline 22–25), Neuro-QoL Fatigue T-scores were lower by 13–17 points, and MFIS total scores were lower by 3, 20, and 9 points across patients. Changes in MFIS cognitive subscores varied, with one patient showing a slight increase (5 → 6) and others showing reductions. One patient transitioned from non-evaluable to evaluable TMT part B performance, while switching cost showed heterogeneous changes across patients. This exploratory case series describes heterogeneous multidomain trajectories across clinical, fatigue, and cognitive measures in gMG. The findings highlight the feasibility of integrating multidomain assessment of non-motor symptoms in this population, without supporting causal inferences regarding treatment effects.