Treatment of Myasthenia Gravis and Tetanus.

By: Dr. Premlata Das.

Myasthenia Gravis

Acquired autoimmune disorder. Skeletal muscle fatiguability & weakness.

Associated with production of IgG antibody against ACh receptors (Nm). Pathogenesis: receptors amplitute of EPP failure to trigger AP.

Symptoms: Weakness of muscles & fatigue, that worsens on exercise, but allayed on rest.

No muscular pain.
Initially ptosis, diplopia, slurring of speech, difficulty in swallowing, weakness of extremities.

Diagnosis: 1. Measurement of anti-ACh receptor titre by immuno-precipitation assay. 2. EMG recording of response to nerve stimulation. 3. Edrophonium test: use 1-2 mg i.v for test dose. 5- 8 mg i.v, If patient shows signs of improvement of muscle strength, then its MG. 4. Anti-striated muscle antibody. 5. Thymoma identification & CT scan of thymus.

Treatment: 1. Reversible anti AChE intermediate duration of action. Neostigmine 15- 30 mg/ 6 hrly/ oral. Pyridostigmine 60-120 mg/ 4-6 hrly/oral.

Titrate doses during prolonged therapy to prevent myasthenic/ cholinergic crisis. S/E: Muscarinic: flushing, salivation, sweating etc. Nicotinic: Ms fasciculations, twitching, tremors.

Drugs that aggravate MG: Antibiotics : Aminoglycosides, Polymixin

Antiarrhythmics: Procainamide, Quinidine, propanolol Morphine Others: d-tubocurarine, Quinine, Lithium.

Other therapeutic measures: Glucocorticoids: 10mg OD/ alternate days. Doses increased slowly.

Immunosuppressants: Azathioprine, Cyclosporine Thymectomy . Plasmapheresis

Tetanus

Neurologic disorder Generalized, neonatal, localized forms.

Causative agent: Clostridium tetani.

Toxin: Tetanospasmin Causes increased muscle tone & spasms.

Clinical manifestations: 1st sign: tone of masseter ms trismus or lockjaw.

Dyaphagia, stiffness/ pain in neck, shoulder, back rigid abdomen, stiff proximal limb muscles.

Gimace or sneer appearance, Opisthotonos.

Laryngospasm or sustained spasm of ventilatory muscles. Death due to exhaustion, asphyxia or aspiration pneumonia.

Goals of treatment: Eliminate source of toxin.

Neutralize unbound toxin. Prevent muscle spasm

Monitor patient in quiet room in ICU & provide support.

Cleaning & thorough debridement of wound necessary. Antibiotic therapy: To eradicate vegetative cells. Benzylpenicillin 600 mg i.v/ 6 hrly. Metronidazole 500 mg, q.i.d. Erythromycin/ Clindamycin if allergic.

Antitoxin to neutralize circulating toxin & unbound toxin in wounds. Human tetanus immuneglobulin (TIG) preferred. 3000- 6000 U, i.m., in divided doses. Alternative: Equine tetanus antitoxin cheaper, shorter half life.

Control of muscle spasms:- Diazepam - In cases of unresponsive spasms: nondepolarizing neuromuscular blocking agents.

Respiratory care: - Intubation or tracheostomy may be required. - Provide mechanical ventilation.

-

Additional measures: Hydration & nutritional requirements should be met. Physiotherapy. Heparin.

Prevention: By active immunization. Immunize recovering patients

1st

& 2nd dose 4 8 weeks apart. 3rd dose 6- 12 months later. Booster dose every 10 years.