Myasthenia Gravis
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.
Other therapeutic measures: Glucocorticoids: 10mg OD/ alternate days. Doses increased slowly.
Tetanus
Dyaphagia, stiffness/ pain in neck, shoulder, back rigid abdomen, stiff proximal limb muscles.
Laryngospasm or sustained spasm of ventilatory muscles. Death due to exhaustion, asphyxia or aspiration pneumonia.
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.
Additional measures: Hydration & nutritional requirements should be met. Physiotherapy. Heparin.
& 2nd dose 4 8 weeks apart. 3rd dose 6- 12 months later. Booster dose every 10 years.