Myasthenia gravis

Sivagami*

ANS, Kauvery Hospital, Salem, Tamil Nadu

*Correspondence

Abstract

Myasthenia gravis is an autoimmune neuromuscular disorder that may progress life- threatening myasthenic crisis. Mostly autoimmune myasthenia gravis is complicated by respiratory failure requiring intensive care management. The patient was treated with intravenous immunoglobulin and Rituximab, underwent tracheostomy, and was later successfully decannulated. With comprehensive multidisciplinary medical and nursing care, the patient showed significant clinical improvement and was discharged in stable condition.

Key words: Myasthenia gravis; Hyponatremia; Diabetes mellitus

Introduction

Myasthenia gravis is a chronic autoimmune neuromuscular disorder characterized by weakness and fatigability of voluntary muscles due to impaired neuromuscular transmission. Myasthenic crisis is a serious and potentially life-threatening complication, marked by respiratory muscle involvement requiring ventilatory support. Early recognition, prompt immunomodulatory therapy, and comprehensive nursing care are essential for reducing morbidity and improving patient outcomes.

Patient History: Known case of systemic Hypertension /Type 2 diabetes mellitus / Hypothyroidism on treatment.

Clinical Findings

On admission, the patient presented with generalized muscle weakness, easy fatigability, and respiratory distress. Neurological examination revealed reduced muscle strength with fatigability, while bulbar involvement was suggested by difficulty in swallowing. The patient developed respiratory muscle weakness necessitating ventilatory support. Vital signs were closely monitored, and no focal neurological deficits were noted. Clinical features were consistent with myasthenic crisis.

Investigations

Baseline laboratory investigations were performed on admission. Routine blood tests showed electrolyte imbalance with hyponatremia, while blood glucose levels were elevated in view of underlying diabetes mellitus. Platelet counts were reduced, consistent with secondary immune thrombocytopenic purpura. Arterial blood gas analysis indicated respiratory compromise during the acute phase. Radiological and clinical assessments supported the diagnosis of myasthenic crisis. Further evaluations were carried out to monitor response to immunotherapy and supportive management.

Special investigation

Serum – Acetylcholine Receptor Antibodies – Increase more than 8.0 nmol/L.

Diagnosis

The patient was diagnosed with autoimmune myasthenia gravis presenting as myasthenic crisis, based on clinical features of progressive neuromuscular weakness and respiratory failure requiring ventilatory support. The diagnosis was further supported by the patient’s response to immunomodulatory therapy. The clinical course was complicated by associated comorbidities including type 2 diabetes mellitus, systemic hypertension, hyponatremia suggestive of syndrome of inappropriate antidiuretic hormone secretion, and secondary immune thrombocytopenic purpura.

Management

The patient was managed in the intensive care unit with close respiratory monitoring and ventilatory support. Immunomodulatory therapy with intravenous immunoglobulin was administered, followed by Rituximab for disease control. Due to prolonged respiratory failure, a tracheostomy was performed and later successfully decannulated. Supportive management included glycemic control, blood pressure management, correction of electrolyte imbalance, prevention of infections, physiotherapy, and comprehensive nursing care.

Surgical Management

Due to prolonged respiratory failure during myasthenic crisis, the patient underwent an elective tracheostomy to secure the airway clearance, reduced work of breathing, and allowed gradual weaning from mechanical ventilation. Following clinical improvement and restoration of adequate respiratory function, the patient was successfully decannulated without complications.

ICU Management

Following the procedure, the patient was managed in the intensive care unit with continuous monitoring of vital signs, respiratory status, and neurological function. Ventilatory support was continued with gradual weaning as respiratory muscle strength improved. Strict tracheostomy care, chest physiotherapy, and suctioning were provided to maintain airway patience and prevent pulmonary complications. Immunotherapy was continued as prescribed, along with glycemic control, electrolyte monitoring, and infection prevention measures. Comprehensive nursing care played a key role in supporting recovery and ensuring patient safety.

Outcome

The patient showed gradual clinical improvement with stabilization of respiratory and neuromuscular function. Successful weaning from ventilatory support was achieved, followed by decannulation without complication. Metabolic and electrolyte abnormalities were corrected, and associated comorbidities were well controlled. The patient was transferred out of the intensive care unit in stable condition and subsequently discharged with significant functional recovery.

Discharge

The patient was discharged in a stable condition with improved neuromuscular strength and adequate respiratory function on room air. The patients and caregivers were educated regarding medication adherence, recognition of early signs of myasthenic exacerbation, tracheostomy site care, energy conservation techniques, and the importance of regular follow-up. Advice was given on blood glucose and blood pressure monitoring, avoidance of medications that may worsen myasthenia gravis, and adherence to scheduled outpatient reviews.

Conclusion

Myasthenia gravis requires early diagnosis and timely, individualized management to prevent complications. Appropriate medical therapy and surgical intervention, when indicated, along with coordinated multidisciplinary care, lead to favourable outcomes and improved quality of life.

Myasthenia gravis

Myasthenia gravis

Sivagami*

Nightingale Journals