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Myasthenic crisis — ABIM Board MCQ

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HardNeurologyMyasthenic crisisABIM Board

A 64-year-old woman with myasthenia gravis and pneumonia develops dysphagia, weak cough, single-breath count of eight, and forced vital capacity 12 mL/kg. She is alert but tiring. What is the most appropriate next step?

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Correct answer: C — Transfer to ICU and begin rapid immunotherapy

The best answer is “Transfer to ICU and begin rapid immunotherapy”. Bulbar weakness, ineffective cough, and markedly reduced vital capacity indicate impending myasthenic crisis. The patient needs ICU-level serial respiratory assessment, airway and ventilatory readiness, treatment of pneumonia, and rapid immunotherapy with IVIG or plasma exchange. Escalating pyridostigmine alone can increase secretions and does not reverse crisis quickly. Beta blockade and botulinum toxin may worsen neuromuscular transmission, and lumbar puncture is irrelevant.

Reference: International consensus guidance for myasthenia gravis: https://pmc.ncbi.nlm.nih.gov/articles/PMC7884987/