myasthenia gravis case presentation

1. CASE PRESENTATION
MODERATOR-DR.PRIYAM BANERJEE
SPEAKER – DR.GANGA BHAVANI

2. • A 68 year lady presented with h/o of difficulty in swallowing since 1 year
difficulty in chopping vegetables since 1 year
difficulty in speech since 1 year
voice change since 1 year
unable to hold glass since 9 months
sob since 9 months
CHIEF COMPLAINT

3. • She has generalised weakness and fatiguability since 40 years
• Ptosis since 2 years, difficulty in swallowing since 1 year, difficulty in chopping vegetables
since 1 year, difficulty in speech since 1 year, voice change since 1 year, unable to hold glass
since 9 months and sob since 9 months.
• Symptoms worsened with activity, aggravated with stress and relieved on rest.
• No h/o trauma
• No h/o fever, diarrhea
• No h/o weight loss
• No h/o deviation of mouth or weakness of limbs.
• She presented to ER with severe SOB and was intubated in ER in view of gasping state and
poor gcs.
History of present illness

4. Past history – GERD, Multi nodular goitre ( not on medication)
 Family history – Insignificant
Personal history – Non alcoholic , Non smoker
Allergic history – Nil

5. Medication history
1) T. Esmoprazole 40mg OD
2) Syp. Gelusil 10ml OD
3) T. Famotidine sos

6. ON EXAMINATION- DAY1 IN ICU
 AIRWAY – Intubated with 7.5 sized ETT, fixed at 20cm
 BREATHING – Mechanically ventilated with VCV – 40/6/20/380
RR- 20,Equal rise of hemithorax
Oxygenation – P/F 300 as per ABG
CIRCULATION – Warm peripheries
Screening echo – Normal LV function. No RA/RV dilatation.

7. GENERAL EXAMINATION – No pallor,icterus,clubbing,cyanosis,lymphadenopathy,edema
HR-105/min , BP- 120/70mmhg,
Neurological system – GCS- E3VTM6
Pupils- B/L 2mm, Reacting to light
Motor examination - Power – 4/5 in all limbs
Tone – Normal
Reflexes – Normal
Cranial nerves – normal
Sensory system – normal
Fasiculations - absent

8.  RESPIRATORY SYSTEM – BAE heard. No abnormal sounds heard.
CARDIOVASCULAR SYSTEM - S1S2 heard, No murmurs heard
ABDOMINAL – Soft
No organomegaly
BS – present

9. INVESTIGATIONS
LABORATORY –
• Electrolytes – Na – 136, K – 4.2, Cl – 96.7
• Anti cholinesterase antibody – 3.9nmol/L
• Thyroid profile – T3 – 94ng/dl , T4 – 10.4 ug/dl, TSH – 1.4 uIU/ml
• IgE – 231 IU/ml
• D dimer – 0.6 ug/ml
IMAGING –
• MRI BRAIN – No acute changes
• CT CHEST – Partial collapse of RIGHT LL
• CT NECK – Diffuse extensive edema – tonsils, nasopharynx, oropharynx and
laryngopharynx.

10. OTHERS –
• RNS – Decremental response on repetitive stimulation
• Bronchoscopy – Vocal cord palsy – Adductor palsy

11. • Day 1 (12/10/22)
Arousable to pain
Obeying commands
MRI brain – no new changes
• Day 2 (13/10)
Extubated and reintubated
• Day 3 (14/10)
Bronchoscopy – Laryngeal edema
Vocal cord palsy

12. • Day 4 (15/10)
Ach receptor antibodies – positive
RNS – Decremental response to repetitive stimulation
Pulse dose steroids (Inj. Solumedrol 1g) were initiated
Anticholinergics were initiated (tab.pyridostigmine 60mg.tid)
Ig E levels were positive
FVC – 10ml/kg
Not tolerating PSV
• Day 7 (18/10)
1st cycle of plasmapheresis was initiated
Was tolerating PSV
FVC – 40ml/kg
NIP - -10
PO.1 - 2

13. • Day 9 (20/10)
2nd cycle of plasmapheresis was done.
Maintenance steroids (tab.omnacortil 60mg/od) was initiated
• Day 10 (21/10)
Bronchoscopy – No vocal cord palsy, Vocal cords – mobile.
• Day 11 (22/10)
3rd cycle of plasmapheresis was done
• Day 13 (24/10)
4th cycle of plasmapheresis was done

14. • Day 14 (25/10)
Azathioprine was initiated (tab 50mg od).Shifted to room
• Day 16 (27/10)
Decannulated
• Day 17 (28/10)
Discharged with anticholinergics, steroids and immunosuppressant.

15. THANK YOU