Azithromycin-induced myasthenic crisis: Reversibility with calcium gluconateSir, Infections that precipitate acute exacerbations of myasthenia gravis (MG) are managed with antibiotics which themselves have the potential to worsen MG. We report the case of a boy with MG in whom intravenous (iv) azithromycin caused sudden worsening of motor symptoms necessitating endotracheal intubation. The respiratory weakness improved within a few minutes of inravenous (iv) calcium gluconate administration followed by improvement in limb power. Such a rapid reversal suggests that azithromycin probably acts presynaptically suppressing acetylcholine release. Since there is no harmful effect of iv calcium gluconate in postsynaptic defects, we advocate such treatment in all cases of acute worsening of MG due to antibiotics or other substances with less clear site of action.Several antibiotics are known to worsen myasthenia gravis (MG). Still their administration becomes necessary in dire situations. Aminoglycosides are well known to worsen MG. [1] About some newer antibiotics, such adverse effects are not clearly known. However, there are some anecdotal reports of exacerbation of MG with macrolides, such as azithromycin and telithromycin. [2,3] No definite remedy is known for such worsening. We report a case of acute worsening of MG with a macrolide antibiotic azithromycin, which dramatically improved with intravenous (iv) administration of calcium gluconate. As trials on human beings are not possible in specific situations, experience gained over a period of time makes our understanding better. It is for this reason that pharmacovigilance efforts should continue even long after marketing of drugs.A 13-year-old boy presented to the emergency services with acute onset painless difficulty in swallowing with drooling of saliva for two days and generalized weakness for one day. He had had similar symptoms twice in the last one year; on both the occasions, he had responded to iv steroids administered empirically without getting a definite diagnosis. Examination revealed bilateral ptosis without other extraocular weakness, pharyngeal weakness with a nasal twang in voice, neck weakness, and proximal limb weakness. Fatigability could be demonstrated in all groups of muscles. There were no sensory signs and deep tendon reflexes were normal. The child had tonsillitis with bilateral tonsilar hypertrophy. Chest X-ray and CT revealed pneumonia involving left lower lobe without any mediastinal enlargement to suggest thymic hyperplasia. With the provisional diagnosis of MG, a neostigmine test was performed to which the response was immediate and significant. In addition to low dose oral steroids (prednisolone (10 mg/day) and pyridostigmine (60 mg thrice a day)) that he received for two days, iv azithromycin (500 mg single dose infused in one hour) was administered in view of the evidence of active tonsilitis and pneumonia. Within 10min utes of receiving iv azithromycin, the child started having respiratory distress, became cyanosed and unresponsiv...
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