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Myasthenia Gravis

83 year old male in a myasthenia crisis or no

07/23/2008

Question:

My questions come in several parts. First some history. My father who is 83 years old has a history of a-fib, chf, pleural effusions, sick sinus syndrome, pacer placement, prostate cancer and yes Myasthenia Gravis. He was treated in 2000 for the MG with plasmaphoresis tx`s. He took Mestinon for a short time post the tx`s. Since then we have seen him become weaker and weaker. Then this past week he became so SOB and very weak. We took him to the ER and they did blood work, ct scan, xray, blood cultures. None of the tests came back with anything abnormal till they did the Blood gas and he has a 7.1 ph, PC02 95. He was intubated and placed on a vent. They also started him on 2 kinds of antibiotics, mestinon and ventilated him for 48 hours. He was removed from the vent and then a blood test was done for the MG and supposedly came back negative. Is a simple blood test accurate after already receiving mestinon? Is it also accurate after the initial crisis has passed? We are so confused on his care. There are 4 doctors on my fathers case, cardiologist, neurologist, intensivist, and a hospitalist. They cant seem to come together to give us an answer on what really is going on. I need any suggestions and comments from anyone that knows the routine.

Answer:

The situation that you describe is a difficult one.

Having four doctors is both a good thing and a problem. The neurologist should be responsible for the MG care, provided that he/she is very experienced with MG. If you don't have a neurologist who is very experienced with MG, you should probably locate one and transfer care.

The AChR Ab blood test for MG are normal in about 15% patients who have MG. Your dad's blood gas values fit with acidosis due to respiratory failure. While this can be seen with MG in crisis, you must remember that one cannot diagnose MG over the web!

I would recommend that you sit down and talk things over with your doctors: The neurologist will lay out the options for control of MG, and the hospitalist and your PCP should let you know about his overall health/life expectancy aside from MG. All four physicians should advise you about whether or not he could tolerate plasmapheresis, prednisone, IVIG and other forms of immune modulation -- if they are felt to be needed.

Best wishes in this difficult time.

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Response by:

John G Quinlan, MD John G Quinlan, MD
Professor of Neurology
College of Medicine
University of Cincinnati