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Myasthenia Gravis Case Study

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Lori Gerick

on 28 March 2016

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Transcript of Myasthenia Gravis Case Study

Myasthenia gravis
Myasthenia gravis






Case Study

Myasthenia ~Latin for muscle weakness

Gravis~ grave or serious

Disorder of the neuromuscular junction

Causes abnormal weakness and fatigue of muscles affected... improved with rest

Fluctuating weakness of skeletal muscle with remissions & exacerbations

May be associated with tumor of thymus


Worldwide: 100-150 people/million

Twice as many young women than men

Age of onset:
Women – 35 years
Males – 50 years

Autoimmune disease

Impairs ability of ACh

Antibody found with MG:

AChR antibodies




Clinical evaluation/Patient assessments
Blood tests- too look for AChR antibodies
Muscle and nerve tests
Scan of the thymus gland
Thyroid function tests
Electrophysiological investigations- can give false pos and neg results
Ice Pack test
Edrophonium test (a rapid anticholinesterase inhibitor)
Breathing tests are performed on those with chest weakness
Thymectomy – removal of the thymus
Plasma exchange - indicated for management of myasthenic crisis
An immune organ located between the heart and sternum.
The thymus gland is thought to be a main source of the abnormal antibodies.
Usually caused by tumors
All MG diagnosis should undergo scan of the thymus to rule out this as the cause
First line treatment
Inhibiting acetylcholinesterase can boost the concentration of ACh in synapse
facilitate muscle activation and contraction
Pyridostigmine – typical maintenance dose
- 60mg four to six times a day
Side effects – nausea, diarrhea, abdominal cramps, increased saliva/mucus
Propantheline 15mg (taken 15-30mins before pyridostigmine dose)

Immunosuppressant therapy

41-year-old Caucasian male
No children; lived alone in Maine
He used no tobacco, alcohol, or other substances.
Both of his parents had "heart problems"
Drug History
Dignostic Challenge: Myasthenia Gravis in the emergency department
Susan A. Abbot, RN, MS, FNP ~Journal of the American Academy of Nurse Practioners 22 (2010) 468-473
Myasthenia Gravis Association
Clinical Breifing: Myasthenia Gravis
Ann-Marie Mestecky ~British Journal of Neurscience Nursing
JAOA Review Article
Milind J. Kothari, DO ~ JAOA, Vol 104, No. 9 Sept 2004
Yale School of Medicine Myasthenia gravis

By : Christine Braddy & Lori Gerick
Shortness of breath, neck and upper spine pain, shoulder and upper arm weakness.

Could not hold his head up for more than a few minutes at a time

Symptoms were worse with fatigue and improved with rest.

Started two months prior to going to the ER
Five weeks before he went into ER with simular symptoms

Diagnose with Bell's Palsy and sent home with prescriptions for predisone and doxycycline
Past Medical History
Gastroesophogeal reflux disease (GERD)
Mild arthritis of knees
Allergic to penicillin
Examination Day 1
Current medications:
Hydrochlorothiazide-lisinopril (BP med) 25mg/20mg
Omeprazole (heartburn med) 20 mg
Pulse: 106
Respirations: 24
BP: 160/88
BMI: 38
Oxygen saturation on room air ranged from 92%to 98%
Blood tests included complete blood count, complete metabolic panel, and thyroid stimulating hormone. All were within normal limits.
MRI- results unsatisfactory due to paitent movement; no gross abnormality was noted
A neurologist scheduled a MRI of the brain and cervical spine as an outpatient the next day.
Never took place because the paitent returned by ambulance the next morning
His vital signs were within normal range and he attributed his symptoms to anxiety.
Final Diagnosis
Within three days the patient was diagnosed with Myasthenia Gravis after a positive acetylcholine receptor antibody test.
A CAT scan of the chest revealed a mediastinal mass.
Thymectomy (removing thymus) was performed the next day.
Pathology results revealed a benign tumor
Postsurgery- transferred to a nursing facility for medication management, and physical/occupational therapy
Physical Examination Day 2
Changed when compared to previous day
Exhibited left-side ptosis, vertical and lateral nystagmus (fast, uncontrollable movements) of the left eye, decresed motor stregths of the deltoids and neck flexors, and plantar reflex was downgoing
Blood work: creatinine kinase (CK) normal; antinuclear antibody panel; positive
Final Diagnosis Continued...
Medications included:
Pryidostigmine bromide- (anticholinesterase inhibitor) 60mg given by mouth every six hours for symptom control
Immunosuppressive therapy
Prednisone- 80mg once a day
Myasthenic Crisis
Occurs when MG symptoms are severe
Causing respiratory failure
Intublation and ventilation
20% will develop myasthenic crisis
Case Study
A case

report featuring a diagnostic challenge in the emergency departmen
Myasthenia gravis is a pure motor syndrome disease characterized by fluctuating muscle weakness and fatigue and is made worse by sustained muscle use.
In this case, a 41-year-old male was first diagnosed with Bell's Palsy.
Increased complications of his symptoms led to the diagnosis of myasthenia gravis.
Doctors, NP, and PAs, must include MG in the differential diagnosis with any report of a specific muscle weakness that can be reproduced and exacerbated with sustained muscle use.
These considerations will lead to earlier diagnosis and treatment.
Purpose: To describe an instructive case of neurological disease encountered by a NP student in the emergency department.

Data Sources: Findings from the history, physical examination, and diagnostic testing of a 41-year old caucasian male with neck weakness and pain.

Conclusions: MG is a pure motor syndrome disease characterized by fluctuating muscle weakness and fatigue and is exacerbated by sustained muscle use. Usually caused by autoimmune process, chronic & progressive Multiple PT encounters w/healthcare system occurr regularly prior to diagnosis. Many tx options now exist that enhance quality of life and improve function.

Implications for practice: The NP needs to include MG in differential diagnosis w/any report of muscle weakness or neurological, respiratory or ophthalmic complaint. These considerations will lead to earlier diagnosis and tx.
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