UNMASKING A CRISIS : A CASE REPORT ON MYASTHENIA CRISIS PRECIPITATED BY DRUG-DRUG INTERACTION

Abstract

INTRODUCTION

Myasthenia Gravis (MG), although one of the most common autoimmune neuromuscular disorder, is a diagnostic challenge in Emergency Department (ED) setting as Altered Mental Status is a common ED presentation with arrays of differential diagnosis. There are many factors that can exacerbate myasthenia symptoms leading to Myasthenia Crisis including systemic illness, pregnancy and most commonly drugs

CASE REPORT

60 year old lady presented with episode of sudden onset altered mental status and respiratory failure requiring urgent intubation. Patient was subsequently admitted in Intensive Care Unit requiring ventilation for 8 days. She was initially treated as Possible Drug-Drug Interaction before the diagnosis of Myasthenia Crisis was established. Treatment with IV Pyridostigmine and IVIG was initiated and completed. Patient responded well to treatment and subsequently discharged. Retrospective history revealed patient complained of mild dysphagia for the past several months before going for flexible laryngoscope and Oesophagusduodenoscopy (OGDS) under anaesthesia (Midazolam) at private center earlier on the day and was treated for H.pylori infection. She was discharged home with Ganaton, Clarithromycin, Pantoprazole and Amoxicilin before suddenly went unresponsive the same evening prior to ED visit.

DISCUSSION AND CONCLUSION

Ganaton (Itopride), Clarithromycin (Macrolide), Pantoprazole (Proton pump inhibitor), Amoxicilin (Penicilin) and Midazolam (Benzodiazepine) are among the drugs which have been reported to unmask and exacerbate symptoms of Myasthenia Gravis. Individually, these drugs interfere with the neuromuscular transmission by hindering release of Acethylcholine. Collective use synergistically increases their potency and may lead to Myasthenia Crisis. In patient who fits the epidemiological profile, clinical suspicion of Myasthenia Gravis and judicious use of drugs which may exacerbate Myasthenia Crisis via drug-drug interaction needs to be seriously considered