Common Pharmacologic Precipitants of Myasthenic Crisis

Patients with myasthenia gravis  may be seen in the emergency department for symptoms that are  not related to their MG, such as an upper respiratory tract infection or chest pain.

Physicians should be careful in prescribing new medications to patients with MG, as that can precipitate a myasthenic crisis (and therefore cause significant morbidity and mortality). Below is a list of medications that are commonly implicated; an extensive list can be found at www.myasthenia.org/docs/MGFA_medicationsandmg.pdf)

  • Iodinated IV contrast
  • Fluoroquinolones
  • Aminoglycosides
  • Macrolides
  • IV magnesium replacement
  • Beta blockers (metoprolol and labetalol)

Case Challenge # 2

Case Challenge # 2

  • A 42 yo female is admitted with fever and LAD for 5 days. Prior history of IVDU and started on phenytoin for new onset seizures.
  • PE: Tmax 101.8, HR 115, BP 90/50. Tender cervical and axillary LAD, maculopapular rash on face and arms with periorbital edema.


  • Labs: WBC 14k (no Eos), Cr 1.0, AST 235, ALT 345. Blood Cx negative, HIV Ab negative, EBV and CMV serologies show prior exposure.

What is the best management step?

  • A) Broad spectrum abx
  • B) Prednisone
  • C) ART for acute HIV
  • D) Stop phenytoin
  • E) NSAIDs

Look forward to the answer this Friday, 2/6/15!

The VA Health System Leads the Pack in Reducing Nosocomial Infections!

An article from The New York Times this past week highlighted the remarkable reduction in hospital acquired MRSA infections between 2007-2012. According to the CDC, acute care VA hospitals outperformed non-VA hospitals in this key measure of quality care. This impressive feat is attributed to the VA’s implementation of the “MRSA” bundle which is a 4 step process that includes aggressive surveillance of patients with MRSA and compliance with handwashing. This bundle is now being expanded to other multi-drug resistant organisms. Special thanks to Dr. Cuttrell for referring to this article! Check out the article below:

For V.A. Hospitals (and Patients), a Major Health Victory

Advice for Physicians in Training: 40 Tips From 40 Docs

On Being a Doctor

You can be an excellent physician without a stethoscope or a prescription pad, but not without good communication skills. Communication is your most important tool. Tailor your words to the patient, and listen more than you speak. Remember that the physicians who most often run afoul of patients and families (and their lawyers) are those who communicate poorly or not at all.


David Juurlink, Advice for Physicians in Training: 40 Tips From 40 Docs,The Winnower2:e142006.67645 (2014). DOI:10.15200/winn.142006.67645

“Dying Shouldn’t Be So Brutal”

Interesting op-ed piece from The New York Times by Dr. Ira Byock, a palliative care physician, that discusses the “unsafe state of dying in America”. Dr. Byock points out the ways healthcare systems fail to provide the basic safety needs of patients and their families when it comes to end of life care. Just as hospitals are held to high standards when it comes to caring for patients, the author argues that hospice and palliative care services should also be held accountable. Educating physicians in training should include a curriculum that teaches them how to treat patients with terminal diseases and managing their pain as well as talking to them and their families. Check out the article below!