Myasthenia gravis as a ‘stroke mimic’
Editor – Shaik and colleagues (Clin Med December 2014 pp 640–2) elegantly highlight the importance of an accurate history in the diagnosis of myasthenia gravis (MG) and offer important differentials of the condition. However, by not explicitly discussing the possible role of iatrogeny as a contributing factor for the ‘patient's rapid deterioration,’ an important learning point may have been missed.
In the case, the patient's condition appears to have deteriorated further after he was administered gentamicin (for possible aspiration pneumonia) and verapamil (for atrial fibrillation). Both of these drugs can affect neuromuscular transmission and result in clinically significant weakness in patients with MG.1,2 Indeed the British National Formulary registers all aminoglycosides along with two other antibiotics, telithromycin and colistin, as a contraindication in MG. Other agents that could conceivably be administered to critically unwell patients but should be avoided in MG if possible include: high dose intravenous magnesium (pre-eclampsia or severe asthma), intravenous lignocaine for ventricular arrhythmias (safe as a local anaesthetic) and neuromuscular blocking agents.4 If these drugs are given then the patient should be monitored in a high-dependency area, where they are able to receive ventilatory support if acutely needed.
It is not necessary to recall all the medications that ought to be used with caution in patients with MG as these are readily available online.3,4 However, we hope this letter will serve to remind those that might be involved in the care of patients with MG to perform a thorough risk benefit analysis before starting new drugs and have a process for actively monitoring them for early signs of deterioration.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2015 Royal College of Physicians
References
- 1 .↵
- Torda T.
- 2 .↵
- Ribera AD
- 3 .↵
- Myasthenia Gravis Association
- 4 .↵
- Pascuzzi R
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