Podcast # 437 : Myasthenia Gravis
Author: Gretchen Hinson, MD
- Myasthenia gravis (MG) is an antibody mediated autoimmune disorder against the acetylcholine receptors at the neuromuscular junctions.
- Bimodal age distribution (20’s-30’s: women; 60’s-70’s: men)
- Presents with fluctuating muscle weakness typically worse at the end of the day with upper extremities affected more than lower and typically involving facial muscles.
- Myasthenia crisis occurs when muscle fatigue begins to cause respiratory depression
- MG was historically diagnosed with the Tensilon test but now often by EMG
- Treatment of MG crisis involves plasma exchange and IVIG. Those in crisis often require intubation and ICU admission
Gilhus NE. Myasthenia Gravis. N Engl J Med. 2016 Dec 29;375(26):2570-2581. doi: 10.1056/NEJMra1602678. Review. PubMed PMID: 28029925.
Roper J, Fleming ME, Long B, Koyfman A. Myasthenia Gravis and Crisis: Evaluation and Management in the Emergency Department. J Emerg Med. 2017 Dec;53(6):843-853. doi: 10.1016/j.jemermed.2017.06.009. Epub 2017 Sep 12. PubMed PMID: 28916122.
Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD
Author: Jared Scott, MD
- Scombroid is a type of food poisoning associated with dark fish (i.e. tuna, salmon, mackerel) that mimics anaphylaxis.
- Occurs through conversion of histidine to histamine by bacteria in the fish.
- Symptoms include flushing, lips swelling, nausea, diarrhea in setting of recent fish consumption.
- Treat with antihistamines.
Ridolo E, Martignago I, Senna G, Ricci G. Scombroid syndrome: it seems to be fish allergy but… it isn’t. Curr Opin Allergy Clin Immunol. 2016. 16(5):516-21. doi: 10.1097/ACI.0000000000000297.
Patterson R, Little B, Tolan J, Sweeney C. How to manage a urinary catheter balloon that will not deflate. Int Urol Nephrol. 2006;38(1):57-61. Review. PubMed PMID: 16502053
Author: Nick Hatch, MD
- Behcet Disease is an autoimmune disease that can affect any organ system.
- Typical symptoms include recurrent oral and genital ulcers, but more concerning features include skin rashes, ocular problems, and strokes.
- Patients with Behcet disease with hypotension should have low threshold for giving steroids.
Arlt W, Allolio B. Adrenal insufficiency. Lancet, 2003; 361:1881.
Sakane T, Takeno M, Suzuki N, Inaba G. Behçet’s disease. New England Journal of Medicine. 1999; 341:1284.
Author: John Winkler, M.D.
- Angioedema is immediately life-threatening due to airway obstruction.
- Mechanisms include allergic reaction (histamine-related) or bradykinin-related (ACE-inhibitor, C1 esterase inhibitor deficiency).
- The bradykinin-related mechanism will not respond to the traditional meds used for anaphylaxis. Instead, use FFP to replace depleted factors.
- If a patient displays signs of respiratory compromise, intubation is indicated. Anesthesia should be consulted as this will be a very difficult airway.
Author: Aaron Lessen, M.D.
- Icatibant was introduced to treat ACE-inhibitor induced angioendema.
- This type of angioedema is refractory to epinephrine and antihistamines, and is likely mediated by elevated bradykinin.(which is inactivated by ATII and ACE).
- Icatibant initially was shown to reduce facial swelling and airway obstruction in the setting of ACE-I angioedema, but later, better-powered studies showed that it had no benefit compared to standard treatment.
References: Sinert R et al. Randomized Trial of Icatibant for Angiotensin-Converting Enzyme Inhibitor-Induced Upper Airway Angioedema. J Allergy Clin Immunol Pract 2017. PMID: 28552382
Author: Sam Killian, M.D.
- Anaphylaxis is common in the ED. These patients are treated and then usually watched for 4-6 hours.
- Biphasic happens in patients that have a complete resolution of their anaphylaxis for at least an hour, but then have a recurrence that requires pharmacologic intervention. Most of the time this happens 3-6 hours later, but can happen more than 10 hours later.
- More commonly happens in patients that have a delayed presentation, a wide pulse pressure, need multiple doses of epi, require the use of a beta agonist, or are ages 6-9 years old.
- Educate patients about the possibility of Biphasic anaphylaxis before discharge.
Check out this episode!
Author: Peter Bakes M.D.
- Some common causes of monoarticular arthritis include: crystal arthropathies (gout and pseudogout), infection (septic joint), reactive arthritis and acute presentations of chronic arthritides.
- Lyme disease usually presents with a targetoid lesion associated with constitutional symptoms
- The common triad of symptoms associated with reactive arthritis (aka Reiter’s Syndrome) consists of conjunctivitis, urethritis, and arthritis
- Reactive arthritis commonly presents with a history of a GU infection (often chlamydia) or GI infection (Shigella, Campylobacter, Yersinia, Salmonella). It is more common in men and those between 20 and 40 years old.
- Treatment for reactive arthritis is usually supportive.
Run Time: 5 minutes
Author: Peter Bakes M.D.
- Case presentation: 18 year old otherwise healthy male presents to the ED complaining of neck stiffness, headache, and right ankle irritation. The patient recently traveled to Italy in an area endemic of Lyme Disease. The patient 2 weeks prior had a viral infection w/ rhinorrhea and diarrhea. The patient was diagnosed the previous day with a “UTI” and is currently taking antibiotics.
- Other important information that would be useful for evaluation would be a prior evaluation for lyme, known pre-existing joint processes, and previous rheumatoid history.
- The patient had no rash on exam, no associate features of lyme, and no bacteria in the urine, but had noted unilateral conjunctivitis, and a red, inflamed ankle joint.
- Possible causes of presentations of one red, warm, inflamed painful joint: Gouty arthritis, pseudogout, septic joint, lyme arthritis, acute on chronic arthritis, and reactive arthritis.
- This patient was diagnosed with Reiter’s syndrome now known as a reactive arthritis – an antibody response to an infection. Classically presents as a genitourinary or gastrointestinal infection in a young male with the clinical triad of urethritis, conjunctivitis, and arthritis a few weeks after an infection.
Link to Podcast: http://medicalminute.madewithopinion.com/reiter-s-syndrome/
Run Time: 2 minutes
Author: Dr. Nicholas Hatch
- Angioedema is usually caused by an allergic reaction and can be induced by ACE inhibitors as well as tissue plasminogen activator (TPA).
- Angioedema is caused by the build up of bradykinins resulting in the leaking of capillaries and swelling of tissue.
- TPA-induced angioedema is reported to occur in 1.6% of the patients who receive TPA and is more severe than ACE inhibitor-induced angioedema.
- Giving solu-medrol to treat ACE inhibitor-induced angioedema is the standard of care, although its actual benefit is limited.
- FFP and icatibant (which is a bradykinin receptor antagonist) have been shown to provide more benefit in treatment of angioedema. These are much more expensive options than solu-medrol, with the 30 mg of SubQ icatibant costing the hospital $5000 dollars per dose.
- ACE inhibitor-induced angioedema lasts on average 27 hours before the symptoms subside.
Link to Podcast: http://medicalminute.madewithopinion.com/angioedema/
Run Time: 5 minutes
Author: Dr. Jared Scott
- Urticaria means “burning nettles” in Latin.
- Lymph nodes release immunoglobulin IgE and IgG, which trigger mast cells located all over the body to release histamines.
- Along with the well-known acute urticaria, there are chronic types of urticaria, which last longer than six weeks.
- There are many types of urticaria including: dermatographic urticaria, food-induced urticaria, drug-induced urticaria, cholinergic urticaria, solar urticaria, and cold-induced urticaria among others.
Link to Podcast: http://medicalminute.madewithopinion.com/exotic-urticaria