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Yanagihashi M, Okamoto R, Morioka H, Sawada M, Matsumoto S, Ikeda T, Kano O. Coronary spastic angina after the administration of intravenous immunoglobulin in myasthenia gravis: a case report. BMC Neurol 2020; 20:319. [PMID: 32859168 PMCID: PMC7453555 DOI: 10.1186/s12883-020-01901-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/23/2020] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Myasthenia gravis (MG) is an autoimmune disease caused by antibodies that block or destroy nicotinic acetylcholine receptors at the neuromuscular junction. Most of MG patients need immunosuppression agents in addition to treatments that alleviate the symptoms. Intravenous immunoglobulin (IVIg) and plasma exchange are specific treatments given to patients with severe MG and myasthenia gravis crisis. IVIg therapy can cause an increase in serum viscosity; therefore, the risk for thromboembolic events, such as stroke, myocardial infarction, and pulmonary embolism, are reported after IVIg therapy.
Case presentation
An MG patient was treated with pyridostigmine bromide and prednisolone. The patient’s symptoms worsened 26 days after the commencement of treatment and was presented with head drop and dyspnea. The patient was diagnosed with MG crisis and IVIg was initiated. However, the patient reported chest pain and dyspnea 3 days after IVIg had started. An electrocardiogram (ECG) revealed ST elevations in leads II, III, and aVF. A cardiac catheterization was performed and stenosis, obstruction, and sclerosis were ruled out. Glyceryl trinitrate relieved the patient’s symptoms, suggesting coronary spastic angina (CSA).
Conclusions
We report the first case of CSA after IVIg. Practitioners should be aware of the potential risks of CSA when administering IVIg for MG patients, in particular in old patients with vascular risk factors.
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Niazi M, Iqbal QZ, Zia Z, Sattar SBA, Lafferty J. Rare Case of Iatrogenic Myocardial Infarction Induced by Use of Pyridostigmine. Cureus 2020; 12:e9849. [PMID: 32953356 PMCID: PMC7497766 DOI: 10.7759/cureus.9849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Myasthenia gravis is an auto-immune disease that results in muscle weakness caused by antibodies released against acetylcholine receptors at the presynaptic membrane. Treatment options include acetylcholinesterase medications that cause a wide range of side-effects by increasing the concentration of acetylcholine at the synaptic cleft. One peculiar side effect seen is the precipitation of myocardial infarction caused by an excess of acetylcholine especially among elderly females. We present an interesting case of an 88-year-old female with a history of lung cancer newly diagnosed with paraneoplastic myasthenia gravis, started on treatment with prednisone 40 mg daily, and pyridostigmine 60 mg every six hours. She initially showed remarkable improvement in symptoms within a few hours, however, one day later, the patient developed sudden onset of chest pain radiating towards her left arm. A 12-lead electrocardiogram (EKG) showed diffuse ST-elevation in anterior leads and cardiac enzymes were found to be elevated. Pyridostigmine was stopped and the patient was started on heparin. The patient underwent cardiac catheterization which showed 50% stenosis in the right coronary artery (RCA) and 70% in the left anterior descending artery (LAD). The patient was monitored in the cardiac care unit (CCU) for 24 hours and later on discharged home on oral prednisone. It is a common practice to start treatment with anti-cholinesterase medications in newly diagnosed patients of myasthenia gravis, however, these medications can precipitate myocardial ischemia by coronary vasogenic spasm or by their arrhythmogenic effect. It is important to be aware of these outcomes while starting patients on these medications.
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Affiliation(s)
- Muhammad Niazi
- Internal Medicine, Northwell Health-Staten Island University Hospital, New York, USA
| | - Qasim Z Iqbal
- Internal Medicine, Northwell Health-Staten Island University Hospital, New York, USA
| | - Zeeshan Zia
- Internal Medicine, Northwell Health-Staten Island University Hospital, New York, USA
| | - Saud Bin Abdul Sattar
- Internal Medicine, Northwell Health-Staten Island University Hospital, New York, USA
| | - James Lafferty
- Cardiology, Northwell Health-Staten Island University Hospital, New York, USA
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Kolker S, Tzivoni D, Rosenmann D, Meyler S, Ioscovich A. Neostigmine induced coronary artery spasm: A case report and literature review. J Anaesthesiol Clin Pharmacol 2017; 33:402-405. [PMID: 29109645 PMCID: PMC5672522 DOI: 10.4103/0970-9185.173337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Neostigmine is a cholinesterase inhibitor which does not cross the blood brain barrier and a commonly used for reversal of nondepolarizing muscle relaxants. In the following case report, we present a patient who developed coronary artery spasm, after the administration of repeated doses of neostigmine. Ours is the first case to demonstrate such a longstanding coronary artery vasospasm that lasted several hours in response to neostigmine, resulting in myocardial damage and left ventricular dysfunction. We would like to draw the attention of the anesthesiologists to this rare effect that may lead to perioperative cardiac complications.
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Affiliation(s)
- Shimon Kolker
- Department of Cardiology, Perioperative Medicine and Pain Treatment, Shaare-Zedek Medical Center, Hebrew University, Hadassah Medical School, Jerusalem, Israel
| | - Dan Tzivoni
- Department of Cardiology, Perioperative Medicine and Pain Treatment, Shaare-Zedek Medical Center, Hebrew University, Hadassah Medical School, Jerusalem, Israel
| | - David Rosenmann
- Department of Cardiology, Perioperative Medicine and Pain Treatment, Shaare-Zedek Medical Center, Hebrew University, Hadassah Medical School, Jerusalem, Israel
| | - Shmuel Meyler
- Department of Cardiology, Perioperative Medicine and Pain Treatment, Shaare-Zedek Medical Center, Hebrew University, Hadassah Medical School, Jerusalem, Israel
| | - Alexander Ioscovich
- Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare-Zedek Medical Center, Hebrew University, Hadassah Medical School, Jerusalem, Israel
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Zis P, Dimopoulos S, Tavernarakis A, Nanas S. Myocardial pathology associated with myasthenia gravis. J Clin Neuromuscul Dis 2015; 16:228. [PMID: 25996972 DOI: 10.1097/cnd.0000000000000079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Panagiotis Zis
- *Department of Neurology, Evangelismos General Hospital, Athens, Greece †1st Critical Care Medicine Department, Evangelismos General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Shivamurthy P, Parker MW. Cardiac manifestations of myasthenia gravis: A systematic review. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.ijcme.2014.08.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zis P, Dimopoulos S, Markaki V, Tavernarakis A, Nanas S. Non-coronary myocardial infarction in myasthenia gravis: Case report and review of the literature. World J Cardiol 2013; 5:265-269. [PMID: 23888198 PMCID: PMC3722426 DOI: 10.4330/wjc.v5.i7.265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 06/10/2013] [Accepted: 07/05/2013] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular adverse events in patients with myasthenia gravis (MG) are rare, but the early recognition of such events is crucial. We describe a case of a non-coronary myocardial infarction (MI) during the initial treatment period with pyridostigmine bromide in a female patient with MG. Clinicians should be cautious about the appearance of potential MI in patients with MG. A baseline electrocardiogram is advocated, when the early recognition of the MI clinical signs and the laboratory findings (myocardial markers) are vital to the immediate and appropriate management of this medical emergency, as well as to prevent future cardiovascular events. In this case report possible causes of myocardial adverse events in the context of MG, which may occur during the ongoing treatment and the clinical course of the disease, are discussed.
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Patra S, Singh AP, Srinivas BC, Manjunath CN. Myasthenia crisis following percutaneous coronary intervention in a patient with late onset myasthenia gravis: successful treatment of a unique case. Cardiovasc Interv Ther 2013; 28:279-81. [PMID: 23277348 DOI: 10.1007/s12928-012-0154-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 12/20/2012] [Indexed: 11/30/2022]
Abstract
A 70-year-old female, known case of late onset myasthenia gravis for last 1 year was admitted with effort angina. Coronary angiogram revealed presence of significant lesion in the proximal part of right coronary artery. She had undergone percutaneous coronary intervention. Following angioplasty she developed recurrent ventricular tachycardia and respiratory distress. She developed myasthenia crisis and was put on ventilator. She had undergone through plasmapheresis thrice as anti-acetylcholine receptor antibody titres were very high. Medline search revealed no previous report of similar case. We are reporting the first case where myasthenia crisis was triggered by percutaneous coronary intervention and was treated successfully.
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Affiliation(s)
- Soumya Patra
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bannerghatta Road, Bangalore, 560069, Karnataka, India.
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Chiavistelli P, Cei M, Carmignani G, Bartolomei C, Mumoli N. Pseudoischemic electrocardiogram in myasthenia gravis with thymoma: reversibility after thymectomy. Clin Cardiol 2009; 32:E75-8. [PMID: 19330853 PMCID: PMC6653304 DOI: 10.1002/clc.20309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Accepted: 09/07/2007] [Indexed: 11/11/2022] Open
Abstract
Abnormal ST T-wave changes can be found at presentation in various noncoronary disorders; misinterpretation of these patterns as ischemic heart disease can lead to erroneous diagnosis and treatment. Here we present a case of myasthenia gravis (MG) with thymoma, in which the resting electrocardiogram (ECG) led to a misleading diagnosis of myocardial ischemia. After thymectomy, the ECG resumed a normal pattern. Myasthenia gravis is not usually considered in the differential diagnosis of conditions associated with an abnormal ECG. The combination of dysphagia, dyspnoea, ECG changes, and creatine kinase (CK) elevations may easily bring to mind an erroneous and possibly deleterious diagnosis of myocardial ischemia.
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Affiliation(s)
| | - Marco Cei
- Department of Internal Medicine, Livorno Hospital, Livorno, Italy
| | | | - Carlo Bartolomei
- Department of Internal Medicine, Livorno Hospital, Livorno, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Livorno Hospital, Livorno, Italy
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Comerci G, Buffon A, Biondi-Zoccai GGL, Ramazzotti V, Romagnoli E, Savino M, Rebuzzi AG, Biasucci LM, Loperfido F, Crea F. Coronary vasospasm secondary to hypercholinergic crisis: an iatrogenic cause of acute myocardial infarction in myasthenia gravis. Int J Cardiol 2005; 103:335-7. [PMID: 16098399 DOI: 10.1016/j.ijcard.2004.06.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2004] [Accepted: 06/17/2004] [Indexed: 02/05/2023]
Abstract
Patients with myasthenia gravis undergo lifelong treatment with anticholinesterase agents. While the heart is usually unaffected by this disease, clinicians should bear in mind the potential adverse interaction between cardiac function and the underlying myasthenic disease or its specific medications. In the present article we report, to the best of our knowledge for the first time in the literature, a case of vasospastic acute myocardial infarction due to iatrogenic hypercholinergic crisis secondary to anticholinesterase therapy in an elderly female with myasthenia gravis. This clinical vignette emphasizes the importance of taking into account the potential vasospastic effect of anticholinesterase drugs. Indeed, prompt recognition of the pathophysiology of myocardial ischemia due to iatrogenic hypercholinergic crisis is pivotal to the timely and appropriate management of this medical emergency, as well as prevention of future recurrences.
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Kido K, Mizuta K, Mizuta F, Yasuda M, Igari T, Takahashi M. Coronary vasospasm during the reversal of neuromuscular block using neostigmine. Acta Anaesthesiol Scand 2005; 49:1395-6. [PMID: 16146484 DOI: 10.1111/j.1399-6576.2005.00832.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Alcantara J, Plaugher G, Araghi HJ. Chiropractic care of a pediatric patient with myasthenia gravis. J Manipulative Physiol Ther 2003; 26:390-4. [PMID: 12902968 DOI: 10.1016/s0161-4754(03)00072-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To describe the chiropractic care of a pediatric patient with complaints associated with myasthenia gravis. Clinical features A 2-year-old girl was provided chiropractic care at the request and consent of her parents for complaints of ptosis and generalized muscle weakness (ie, lethargy), particularly in the lower extremities. Prior to entry into chiropractic management, magnetic resonance imaging of the brain and acetylcholine receptor antibody tests were performed with negative results. However, the Tensilon test was positive and the diagnosis of myasthenia gravis was made by a pediatrician and seconded by a medical neurologist. Intervention and outcome The patient was cared for with contact-specific, high-velocity, low-amplitude adjustments to sites of vertebral subluxation complexes in the upper cervical and sacral spine. The patient's response to care was positive and after 5 months of regular chiropractic treatment her symptoms abated completely. CONCLUSION There are indications that patients suffering from disorders "beyond low back pain" as presented in this case report may derive benefits from chiropractic intervention/management.
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Affiliation(s)
- Joel Alcantara
- Research Director, International Chiropractic Pediatric Association, Media, Pa, and Research Associate, Gonstead Clinical Studies Society, Santa Cruz, Calif, USA
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2001; 10:263-78. [PMID: 11505947 DOI: 10.1002/pds.548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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