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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...

Background As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected. Aims The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019. Methods The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points. Results A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods. Conclusions Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe.

Background and Purpose: Occurrence of stroke has been reported among patients with COVID-19. The present study compares clinical features and outcomes of stroke patients with and without COVID-19. Methods: The COVID-19 Stroke Study Group (CSSG) is a multicentric study in 18 sites across India to observe and compare the clinical characteristics of patients with stroke admitted during the current pandemic period and a similar epoch in 2019. The present study reports patients of stroke with and without COVID-19 (CoVS and non-CoVS, respectively) seen between February 2020 and July 2020. Demographic, clinical, treatment, and outcome details of patients were collected. Results: The mean age and gender were comparable between the two groups. CoVS patients had higher stroke severity and extent of cerebral involvement on imaging. In-hospital complications and death were higher among CoVS patients (53.06% vs. 17.51%; P < 0.001) and (42.31% vs. 7.6%; P < 0.001), respectively. At 3 months, higher mortality was observed among CoVS patients (67.65% vs. 13.43%; P < 0.001) and good outcome (modified Rankin score [mRS]: 0–2) was seen more often in non-CoVS patients (68.86% vs. 33.33%; P < 0.001). The presence of COVID-19 and baseline stroke severity were independent predictors of mortality. Conclusions: CoVS is associated with higher severity, poor outcome, and increased mortality. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and baseline stroke severity are independent predictors of mortality.