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• W2039950624 abstract "Back to table of contents Previous article Next article LettersFull AccessMyasthenic Crisis May Mimic Antipsychotic-Induced Extrapyramidal SyndromesYu-Hui Chiu, M.D., Albert C. Yang, M.D., Chii-Hwa Chern, M.D., and Chorng-Kuang How, M.D.Yu-Hui ChiuSearch for more papers by this author, M.D., Albert C. YangSearch for more papers by this author, M.D., Chii-Hwa ChernSearch for more papers by this author, M.D., and Chorng-Kuang HowSearch for more papers by this author, M.D.Published Online:1 Apr 2011AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Although anticholinergic agents show highly selective muscarinic receptor-blockage, they may cause little, but clinically significant, blockade of acetylcholine at nicotinic receptor sites, which the antibodies of myasthenia gravis (MG) directly affect.1 Gyawali and Rangedara have reported on a man with undiagnosed MG who developed a myasthenic crisis requiring intubation after treatment with the muscarinic antagonists oxybutynin and hyoscine.2 We present a 26-year-old woman schizophrenia patient with coexisting, undiagnosed MG, who developed acute respiratory failure while being treating with biperiden, an anticholinergic medication.Case ReportA 26-year-old single, jobless woman had had schizophrenia for 4 years, with persistent auditory hallucinations and systemized delusions. Initially, she received amisulpiride 200 mg–400 mg/day intermittently for 3 years. Six months before, her psychotic symptoms had become worse, and her medication was shifted to quetiapine 150 mg/day. General weakness, hoarseness, dysarthria, difficultly swallowing, and shortness of breath began 3 weeks after the quetiapine treatment. As antipsychotic-induced extrapyramidal syndromes (EPS) was suspected, quetiapine was discontinued. The EPS-like symptoms were improved after treatment with clozapine 12.5 mg/day and biperiden 2 mg/day. She was maintained on this regimen until her psychosis flared up again 4 months later. The clozapine was then titrated to 50 mg/day, and biperiden was increased to 4 mg/day. Ten days later, progressive dysphonia, dysphagia with persistent drooling, and ptosis were noted. She was sent to our emergency department, where vital signs showed a blood pressure of 113/80 mmHg, a pulse rate of 129 bpm, and a respiratory rate of 20/min. Fibroscopy was done, with the impression of vocal cord dyskinesia. We suspected clozapine-associated EPS and prescribed intramuscular injection of biperiden. Sudden onset of desaturation with hypercapnic hypoxic respiratory failure (arterial blood gas revealed respiratory acidosis, with pH: 6.957, p CO2: 148.1 mm Hg, p O2: 58.1 mm Hg, and oxygen saturation 58.1%) occurred 3 hours later. We performed emergent endotracheal tube insertion. Subsequent examinations showed 1) unremarkable chest film; 2) sinus tachycardia on ECG; 3) cardiac enzymes within normal range; and 4) brain, neck, and chest computer tomography revealed no abnormal organic lesions. Four days later, her respiratory pattern was improved, and the endotracheal tube was extubated. During this period, she continued to use clozapine 25 mg/day and biperiden 2 mg/day. However, dyspnea with respiratory failure recurred 10 days after the endotracheal tube was removed. Because MG was suspected, acetylcholine receptor antibody was checked and showed 0.66 nmoles/liter (reference range: <0.5 nmoles/liter). Electromyography also revealed significant decrement on the repetitive nerve stimulation test, and MG was diagnosed. She was treated with pyridostigmine and plasmapheresis and recovered uneventfully 2 weeks later.DiscussionExcept for biperiden, our patient had been prescribed quetiapine and clozapine. The two medications also pose a significant anticholinergic effect and could worse preexisting MG symptoms.3 Since there are significant overlaps of symptoms between MG and EPS presentations,4 it is important for physicians to make timely differential diagnosis for unexplained EPS while dealing with certain mentally ill patients being treated with antipsychotics.5 This report also highlights the idea that physicians should consider MG in any patient with unexpected respiratory failure and should prescribe anticholinergics more carefully.Department of Emergency Medicine Taipei Medical University-Wan Fang Hospital Taipei, TaiwanDepartment of Psychiatry Chu-Tung Veterans Hospital Hsinchu, TaiwanDepartment of Emergency Medicine Taipei Veterans General Hospital Taipei, TaiwanSchool of Medicine National Yang-Ming University Taipei, TaiwanDivision of Psychiatry National Yang-Ming University Taipei, Taiwan1. Bershad EM , Feen ES , Suarez JI : Myasthenia gravis crisis. South Med J 2008; 101:63–69Crossref, Medline, Google Scholar2. Gyawali P , Rangedara DC : Iatrogenically revealed myasthenia gravis. Int J Clin Pract 1999; 53:645Medline, Google Scholar3. Diez-Tejedor E , Cruz Martinez A , Barreiro Tella P , et al.: [A case of myasthenia gravis made worse by the administration of reserpine.] Rev Clin Esp 1985; 177:94Medline, Google Scholar4. Dorrell W : Myasthenia gravis and schizophrenia. Br J Psychiatry 1973; 123:249Crossref, Medline, Google Scholar5. Pierre J : Extrapyramidal symptoms with atypical antipsychotics: incidence, prevention, and management. Drug Saf 2005; 28:191–208Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByBrief psychotic disorder revealing a SARS-COV-2 encephalopathy in a patient with myasthenia gravis: A case reportL'Encéphale, Vol. 10Psychopharmacological Treatments for Mental Disorders in Patients with Neuromuscular Diseases: A Scoping Review28 January 2022 | Brain Sciences, Vol. 12, No. 2Worsening of myasthenia due to antiepileptic, antipsychotic, antidepressant, and sedative medication: An estimation of risk based on reporting frequency1 March 2021 | European Journal of Neurology, Vol. 28, No. 7Worsening of Myasthenia Gravis After Administration of Antipsychotics for Treatment of SchizophreniaJournal of Clinical Psychopharmacology, Vol. 37, No. 5Neuromuscular Disorders, Vol. 26, No. 4-5Asenapine-Associated Myasthenic SyndromeJournal of Clinical Psychopharmacology, Vol. 35, No. 1 Volume 23Issue 2 Spring 2011Pages E36-E37 Metrics PDF download History Published online 1 April 2011 Published in print 1 April 2011" @default.
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• W2039950624 title "Myasthenic Crisis May Mimic Antipsychotic-Induced Extrapyramidal Syndromes" @default.
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