A 68-year-old woman presented with difficulty swallowing, speaking, and holding objects for 1-2 years. She was recently intubated for severe shortness of breath. Her symptoms were consistent with myasthenia gravis, which was confirmed by positive acetylcholine receptor antibodies and decremental response on repetitive nerve stimulation testing. She received pulse dose steroids, anticholinergics, and 4 cycles of plasmapheresis with improvement. Her vocal cords became mobile and she was discharged on steroids, azathioprine and anticholinergics.

1. CASE PRESENTATION
MODERATOR-DR.PRIYAM BANERJEE
SPEAKER – DR.GANGA BHAVANI

2. • A 68 year lady presented with h/o of difficulty in swallowing since 1 year
difficulty in chopping vegetables since 1 year
difficulty in speech since 1 year
voice change since 1 year
unable to hold glass since 9 months
sob since 9 months
CHIEF COMPLAINT

3. • She has generalised weakness and fatiguability since 40 years
• Ptosis since 2 years, difficulty in swallowing since 1 year, difficulty in chopping vegetables
since 1 year, difficulty in speech since 1 year, voice change since 1 year, unable to hold glass
since 9 months and sob since 9 months.
• Symptoms worsened with activity, aggravated with stress and relieved on rest.
• No h/o trauma
• No h/o fever, diarrhea
• No h/o weight loss
• No h/o deviation of mouth or weakness of limbs.
• She presented to ER with severe SOB and was intubated in ER in view of gasping state and
poor gcs.
History of present illness

4. Past history – GERD, Multi nodular goitre ( not on medication)
 Family history – Insignificant
Personal history – Non alcoholic , Non smoker
Allergic history – Nil

5. Medication history
1) T. Esmoprazole 40mg OD
2) Syp. Gelusil 10ml OD
3) T. Famotidine sos

6. ON EXAMINATION- DAY1 IN ICU
 AIRWAY – Intubated with 7.5 sized ETT, fixed at 20cm
 BREATHING – Mechanically ventilated with VCV – 40/6/20/380
RR- 20,Equal rise of hemithorax
Oxygenation – P/F 300 as per ABG
CIRCULATION – Warm peripheries
Screening echo – Normal LV function. No RA/RV dilatation.

7. GENERAL EXAMINATION – No pallor,icterus,clubbing,cyanosis,lymphadenopathy,edema
HR-105/min , BP- 120/70mmhg,
Neurological system – GCS- E3VTM6
Pupils- B/L 2mm, Reacting to light
Motor examination - Power – 4/5 in all limbs
Tone – Normal
Reflexes – Normal
Cranial nerves – normal
Sensory system – normal
Fasiculations - absent

8.  RESPIRATORY SYSTEM – BAE heard. No abnormal sounds heard.
CARDIOVASCULAR SYSTEM - S1S2 heard, No murmurs heard
ABDOMINAL – Soft
No organomegaly
BS – present

9. INVESTIGATIONS
LABORATORY –
• Electrolytes – Na – 136, K – 4.2, Cl – 96.7
• Anti cholinesterase antibody – 3.9nmol/L
• Thyroid profile – T3 – 94ng/dl , T4 – 10.4 ug/dl, TSH – 1.4 uIU/ml
• IgE – 231 IU/ml
• D dimer – 0.6 ug/ml
IMAGING –
• MRI BRAIN – No acute changes
• CT CHEST – Partial collapse of RIGHT LL
• CT NECK – Diffuse extensive edema – tonsils, nasopharynx, oropharynx and
laryngopharynx.

10. OTHERS –
• RNS – Decremental response on repetitive stimulation
• Bronchoscopy – Vocal cord palsy – Adductor palsy

11. • Day 1 (12/10/22)
Arousable to pain
Obeying commands
MRI brain – no new changes
• Day 2 (13/10)
Extubated and reintubated
• Day 3 (14/10)
Bronchoscopy – Laryngeal edema
Vocal cord palsy

12. • Day 4 (15/10)
Ach receptor antibodies – positive
RNS – Decremental response to repetitive stimulation
Pulse dose steroids (Inj. Solumedrol 1g) were initiated
Anticholinergics were initiated (tab.pyridostigmine 60mg.tid)
Ig E levels were positive
FVC – 10ml/kg
Not tolerating PSV
• Day 7 (18/10)
1st cycle of plasmapheresis was initiated
Was tolerating PSV
FVC – 40ml/kg
NIP - -10
PO.1 - 2

13. • Day 9 (20/10)
2nd cycle of plasmapheresis was done.
Maintenance steroids (tab.omnacortil 60mg/od) was initiated
• Day 10 (21/10)
Bronchoscopy – No vocal cord palsy, Vocal cords – mobile.
• Day 11 (22/10)
3rd cycle of plasmapheresis was done
• Day 13 (24/10)
4th cycle of plasmapheresis was done

14. • Day 14 (25/10)
Azathioprine was initiated (tab 50mg od).Shifted to room
• Day 16 (27/10)
Decannulated
• Day 17 (28/10)
Discharged with anticholinergics, steroids and immunosuppressant.

15. THANK YOU