Letter to Editor
Management of myasthenic crisis Sir, I read with interest the recent article by Murthy et al.[1] It provides excellent data regarding the management and outcome of patients with myasthenic crisis. I would like to make certain observations. First, Murthy et al have utilized the neostigmine test for confirmation of diagnosis. I would like to emphasize that the edrophonium (Tensilon) test is an excellent alternative for this purpose. It may even be better as the test result is obvious in 1-2 minutes, as compared to neostigmine that requires 15-30 minutes. Tensilon test has a relatively high sensitivity and specificity,[2] and the incidence of serious complications is only 0.16%.[3] Secondly, it is important to differentiate myasthenic crisis from cholinergic crisis. The edrophonium test allows for this differentiation and this may help in optimizing the treatment. Thirdly, Murthy et al started all their patients on steroids prior to discharge. We agree with the approach, however, caution is required as steroids may exacerbate weakness in a subgroup of patients with myasthenia. Therefore, it is advisable to keep patients hospitalized after initiating steroids till clinical improvement begins, as exacerbations after that are unusual. Finally, Murthy et al have shown the effectiveness of lowvolume plasma exchanges in myasthenic crisis, which is similar to our observations.[4] It is particularly important in the Indian scenario to minimize the cost of treatment. It is encouraging to note that plasmapheresis was shown to be superior to intravenous immunoglobulins in treating myasthenic crisis in an earlier study.[5]
Sudhir Kumar, G. Rajshekher, S. Prabhakar Department of Neurological Sciences, Apollo Hospitals, Hyderabad - 500 033, India. E-mail:
[email protected]
Authors’ Reply Sir, We thank Kumar and colleagues for his interest in our article published in the March issue of the journal.[1] All the patients were established cases of myasthenia gravis (MG) under follow up in our clinic. The initial diagnosis in the patients was established by neostigmine test and decrement response. This has been stated in the material and methods. We had not used neostigmine to establish the diagnosis of myasthenic crisis in our series. We are very much aware of the safety and superiority of edrophonium over neostigmine, unfortunately the availability is a major limiting factor. A cholinergic crisis is less common than presumed and combination of both crises is often clinically encountered as seen in one of the patients in our series.[2] Steroids were started in all the patients after disease stabilization while they were in the hospital. The initiation to steroids was gradual. Worsening with high-dose steroid occurs 7–14 days after initiation of the high doses and usually lasts less than 1 week. It appears that gradually increasing the dose of steroids over a period reduces the risk of the early worsening of the disease.[3] In patients with MG uncontrolled studies, plasma exchange (PE) have demonstrated efficacy with the onset of improvement within the first week.[4],[5] Randomized controlled studies comparing PE with intravenous immunoglobulin (IVIg) have demonstrated equal efficacy, but significantly fewer and less severe side effects for the IVIg.[6],[7] The data on the efficacy of both these immunomodulators in myasthenic crisis are limited. In a retrospective multicenter study PE (compared with IVIg) was associated with a superior ventilatory status at 2-week and 1-month functional outcome. However, the complication rate was higher with PE compared with IVIg.[8]
J. M. K. Murthy, A. K. Meena,* G. V. S. Chowdary, T. J. Narayanan Departments of Neurology, The Institute of Neurological Sciences, CARE Hospital, and Nizam’s Institute of Medical Sciences,* Hyderabad, India. E-mail:
[email protected]
References 1. 2. 3.
4.
5.
Murthy JM, Meena AK, Chowdary GV, Naryanan JT. Myasthenic crisis: Clinical features, complications and mortality. Neurol India 2005;53:37-40. Pascuzzi RM. The edrophonium test. Semin Neurol 2003;23:83-8. Ing EB, Ing SY, Ing T, Ramocki JA. The complication rate of edrophonium testing for suspected myasthenia gravis. Can J Ophthalmol 2000;35:141-4; discussion 145. Kumar S. Manual (low-volume) plasmapheresis: An effective and safe therapeutic procedure in acute neurological illnesses. Ann Indian Acad Neurol 2004;7:439-40. Stricker RB, Kwiatkowska BJ, Habis JA, Kiprov DD. Myasthenic crisis. Response to plasmapheresis following failure of intravenous gamma-globulin. Arch Neurol 1993;50:837-40.
References 1. 2.
3.
4.
Accepted on 08-04-2005 Neurology India | June 2005 | Vol 53 | Issue 2
Murthy JMK, Meena AK, Chowdary GVS, Narayanan TJ. Myasthenic crisis: Clinical features, complications and mortality. Neurol India 2005: 53: 37-40. Thomas CE, Mayer SA, Gungor Y, Swarup R, Webster EA, Chang I, et al. Myasthenic crisis: Clinical features, mortality complications and risk factors for prolonged intubation. Neurology 1997; 48: 1253-60. Seybold ME, Drachman DB. Gradually increasing doses of prednisone in myasthenia gravis. Reducing the hazards of treatment. N Engl J Med 1974; 290: 81-4. Pinching AJ, Peters DK. Remission of myasthenia gravis following plasma exchange. Lancet 1976; 2: 1373-6.
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Dau PC, Lindstrom JM, Cassel CK, Denys EH, Shev EE, Spitler LE. Plasmapheresis and immunosuppressive drug therapy in myasthenia gravis. N Engl J Med 1977; 297: 1134-40. Gajdos P, Chevert S, Clair B, Tranchant C, Chastang C. Clinical trial of plasma exchange and high-dose intravenous immunoglobulin in myasthenia gravis. Myasthenia Gravis Clinical Study. Ann Neurol 1997; 41: 789-96. Ronager J, Ravnborg M, Hermansen I, Vorstrup S. Immunoglobulin treatment versus plasma exchange in patients with chronic moderate to severe myasthenia gravis. Artif Organs 2001; 25:96773. Qureshi AI, Choudary MA, Akbar MS, et al. Plasma exchange versus intravenous immunoglobulin treatment in myasthenic crisis. Neruology 1999; 52: 62932.
2. 3.
underutilized potential. Neurol India 2005; 53:27-31. Ganapathy K. Telemedicine in the Management of Head Trauma: An Overview. Indian Journal of Neurotraumatology 2004;1:1-7. Ganapathy K. Role of Telemedicine in Neurosciences. Progress in Clinical Neurosciences 2002;17:1-10.
Accepted on 05-05-2005
Authors’ Reply
Accepted on 23-05-2005
Telemedicine in neurology Sir, The publication of a review article ‘Telemedicine in neurology: underutilized potential’ by Misra et al[1] in the March 2005 issue shows that telemedicine in India has at last come of age. The author has rightly pointed out that publications from India in indexed journals in this field are not many. However, telemedicine has been used in clinical neurology and neurosurgery in India since 1999.[2]–[3] Some of us who used this technology as early as 1999, are delighted to note that at last telemedicine is slowly being accepted. It will never ever be possible to provide adequate neurological care to the 800 million Indians living in suburban and rural India where most of us do not live. We have in the last 6 years, given about 12 000 teleconsultations from Chennai alone. Three hundred and seventy-five of the 550 consultations in neurosciences have been review of already treated patients. Excepting touch (even this may be eventually possible) detailed teleneurological examination including visualization of the fundus, evaluating the whole gamut of electrophysiological and neuroimaging investigations is possible today. We have held eight international (multipoint) teleconferences and six national teleconferences in neurosciences alone. A multipurpose mobile van with an X ray, ultrasound, biochemistry laboratory, ECG, teleauscultation, and opthalmoscopic evaluation will shortly be operational. Thanks to a VSAT on top of the van, the teleconsultant will be able to do a detailed clinical evaluation of a villager who is in the van. For the neurologist and neurosurgeon of the future ICT will mean Information and Communication Technology, which he should indeed master.
Sir, We read with interest the comments on our paper entitled ‘Telemedicine in neurology: underutilized potential.’[1] Doubtlessly there is great awareness about the virtues of telemedicine in India and a number of interested groups have been applying it for teleconsultation for patient care. On Medline search, however, only a few articles on teleneurology are seen from India, most of which have been cited in our paper. The groups that have been practicing telemedicine but have not published their experience in Indexed journals are not cited in our paper. It is important that the experience of different groups should be documented and brought to the notice of the scientific community so that the leadership of India in the field of software should also be extended to the field of telemedicine. It is heartening that after the publication of our paper, a few more articles on telemedicine have been published from India and are mentioned in the above-mentioned comments. Currently, there is increasing interest in telemedicine in different regions of our country; however, the application of telemedicine has inherent contradictions. On one hand, telemedicine is needed for the development and health care of remote areas, which are often inaccessible and economically backward. On the other hand, telemedicine requires broadband telecommunication infrastructure, hardware and trained manpower all of which are expensive. However, for interested groups both governmental and private funding agencies should come forward and provide the much needed support. Telemedicine cannot be practiced in isolation; it is a group activity and its essence is connectivity and collaboration. The scope of telemedicine should be widened to include teaching and research besides patient care.
Misra UK, Kalita J, Mishra SK*, Yadav RK* Departments of Neurology and *Endosurgery, Sanjay Gandhi PGIMS, Lucknow, India. E-mail:
[email protected]
K. Ganapathy Department of Telemedicine and Neurosurgery, Apollo Hospitals, Chennai, India. E-mail:
[email protected]
References 1.
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Misra UK, Kalita J, Misra SK, Yadav RK. Telemedicine in neurology:
References 1.
Misra UK, Kalita J, Misra SK, Yadav RK. Telemedicine in neurology: underutilized potential. Neurol India 2005; 53:27-31.
Accepted on 12-05-2005
Neurology India | June 2005 | Vol 53 | Issue 2
